DEPARTMENT OF LICENSING AND CONSUMER AFFAIRS 
Trucking Services and Supply Price Survey Form 
 
 
Name of Business: _____________________________________________________________________ 
Mailing Address: _______________________________________________________________________ 
Physical Address:______________________________                     Cell:__________________________________ 
Tel: ____________________________________________                e-mail:_____________________________________ 
 
Legal Form of your Business (Corp., Partnership, LLC): _____________________________________ 
 
 
Truck Usage:  Trash Removal (   )   Delivery/Transport of Goods (    )  Other: _________________________________   
 
Total Number of Trucks: _____________________________ 
Truck Capacity: 
Truck 1: ____________________________  
  
 
 
Truck 2: ____________________________ 
 
 
 
Truck 3: ____________________________ 
 
 
 
Truck 4: ____________________________ 
 
Price Per Truck : 
Low: $________________________  to High: $______________________________ 
 
 
 
Low: $________________________  to High: $______________________________ 
Low: $________________________  to High: $______________________________ 
 
 
 
Low: $________________________  to High: $______________________________ 
 
Are there additional charges depending on Difficult & Dangerous locations? 
 
 
 
Yes: _____________________    No: ______________________ 
Are there additional charges depending on the amount of cargo required for delivery? 
 
 
 
Yes: _____________________    No: ______________________ 
 
I hereby certify that the information provide herein is true and correct. 
 
______________________________________          _______________________________                ________________ 
 
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