Agency Effective Date: Shipper: Full Legal Name: Agent: Mnemonic: Legal Name: Shipper Contact: Mnemonic: Address: Agent Contact: City, Address: Postal Code/ZIP: City, Phone: Postal Code/ZIP: Fax: Phone: Email Address: Fax: Email Address: Shipper Agencies (please select which apply) Nomination Agent Invoice Agent Account Access (please select which apply) All Mainline Accounts OR specific Mainline accounts: Custody Transfer (CT) / Multi Title Transfer (MTT) Nom Group Nom Group Nom Group Nom Nom Group Nom Group Shipper Signature: ______________________________ __ *This form must be authorized by Shipper Please e-mail a copy of this signed agency form to or fax to (403) 920-2343.
Agency Effective Date: Shipper: Full Legal Name: Mnemonic: Shipper Contact: Address: City, Postal Code/ZIP: Phone: Fax: Email Address: Agent: Legal Name: Mnemonic: Agent Contact: Address: City, Postal Code/ZIP: Phone: Fax: Email Address: Shipper Agencies (please select which apply) Nomination Agent Invoice Agent Account Access (please select which apply) All Mainline Accounts OR specific Mainline accounts: Custody Transfer (CT) / Multi Title Transfer (MTT) Nom Group Nom Group Nom Group Nom Nom Group Nom Group Shipper Signature: ______________________________ __ *This form must be authorized by Shipper Please e-mail a copy of this signed agency form to or fax to (403) 920-2343.
Agency%20Agreement%20Form.docx