AGENT REQUEST FORM Name* Email* Phone* Applying for* ---Independent Freight AgentCommission Sales Agent In what city and state are you currently located?* Who are you currently an agent for? Agent experience* ---YesNo How many years? Do you currently have an active client base of direct customers? ---YesNo Freight moved* TLTLTLFLATBEDSPECIALTY EQUIPMENTDRYTEMPHAZEXPEDITED In the last 30 days how many shipments have you moved?* What percentage of your customer base are 3PL’s or other Brokers ( 1 to 100%)* Why are you interested in joining the Pinnacle Freight Systems team? What can we do to make you successful in this new business venture? Could you refer someone else? Please provide their name and contact information.