AGENT REQUEST FORM Name* Email* Phone* Applying for* ---Independent Freight AgentCommission Sales Agent Are You Currently an active agent? YesNo In what city and state are you currently located?* Who are you currently an agent for? Do you currently have an active client base of direct customers? ---YesNo 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.