Add Agent Request
Add Canadian Agent Request
Branch
Change of Location
Dual Branding
Transfer of Ownership
Required fields are marked with (*)
General Information
(*)Legal Name:
Legal Name Required
(*)Doing Business As:
Doing Business As
(*)Address:
Address Required
(*)City:
City Required
(*)Province/Territory:
Choose Province/Territory
AB
BC
MB
NB
NL
NS
NT
NU
ON
PE
QC
SK
YT
(*)Postal Code:
Postal Code Required.
Invalid Postal Code - Format ANA NAN
(*)Telephone Number:
Telephone Number Required
Invalid Telephone Number (###) ###-####
(*)FAX Number:
FAX Number Required
Invalid FAX Number (###) ###-####
Web Site Address:
(*)Date Businesses Established (mm/dd/yyyy):
Date Required
(*)CRA Business Number (BN):
CRA Business Number Required
Contact Information
(*)Name:
Contact Name Required
(*)Title:
Contact Title Required
(*)Email Address:
Contact Email Required
Invalid Email (Example: John.Doe@Sirva.com)
Van Line Affiliation
List all Van Line Affiliations, starting with the most current.
(*)Van Line Name
(*)Years of Service
Reason For Leaving
Van Line Name Required
Years of Service Required
Please list any industry involvement including committees, training programs, and other interests.
Name
Number of Years
Title
Organizational Information
(*)Type of Company
Choose Type of Company
Private Corporation
Partnership
Sole Proprietorship
(*)Full Name of Owner(s)
(*)Percentage of Share
Owner Name Required
Owner Percent of Share Required
(*)Name of Officer
(*)Title
Officer Name Required
Officer Title Required
Background Information
(*)Has any principal/owner/officer ever been convicted of an offence for which a pardon has not been granted? If yes, please answer the remaining questions in this Background Information section.
Yes
No
Yes or No is required.
(*)Offence(s):
(*)Conviction Dates:
(*)List city and province of conviction(s):
(*)Is any principal/owner/officer currently involved in a pending court action as a resultof, in the course of, or in connection with his or her position with the applicant? If yes, indicate the nature of action and location of the court.
Yes
No
Yes or No is required.
(*)Explain:
Facility Information
Warehouse Street Address:
Square feet devoted to household goods:
Type of Storage:
Loose
Vault
If Vault Storage, how many high?
Dock
Yes
No
Climate Control
Yes
No
Security System
Yes
No
Sprinkler System
Yes
No
Federal Government Approved
Yes
No
Equipment Information
List the number of all Motor Vehicles to be used in Operations.
(*)Tractors
Number of Tractors Required
(*)Trailers
Number of Trailers Required
(*)Straight Trucks
Number of Straight Trucks Required
(*)Pack Vans
Number of Pack Vans Required
Business Information
Do you have Freight Forwarder authority?
Yes
No
Do you have U.S. Motor Carrier authority?
Yes
No
List all motor carriers and freight forwarders currently being used for U.S. Military and/or Government Traffic:
1.
2.
3.
Name and tariff filed with U.S. D.O.T.
Does the Applicant have on file an application for the U.S. D.O.T. for household goods authority?
Yes
No
Has the Applicant been denied or had the U.S. D.O.T. authority revoked within the past three years?
Yes
No
If Applicant has a U.S. D.O.T. safety rating, what is it?
If Applicant has Inter-Province Household Goods Authority, please include the following:
Certificate Number:
Issued Name:
Scope of Operations:
Bank Reference
(*)Name of Bank
(*)Contact Person
(*)Bank Telephone Number
Name of Bank Required
Bank Contact Required
Bank Telephone Number Required
Invalid Telephone Number
History
(*)Please write a brief business history of your company, including the business experience and qualifications of company executives.
Company History Required
Future
(*)Please fill out the prior three year linehaul history and the next three year business plan for interstate booking. Enter linehaul revenue in nearest thousand dollars.
Three Year Net Linehaul Revenue Projection
Third Prior Full Year Actual
Second Prior Full Year Actual
Latest Prior Full Year Actual
First Full Year Affiliation Forecast
Second Full Year Affiliation Forecast
Third Full Year Affiliation Forecast
Corporate Account
3rd Year Prior Amount Required
Invalid Number
2nd Year Prior Amount Required
Invalid Number
1st Year Prior Amount Required
Invalid Number
1st Year Affiliation Amount Required
Invalid Number
2nd Year Affiliation Amount Required
Invalid Number
3rd Year Affiliation Amount Required
Invalid Number
Consumer
3rd Year Prior Amount Required
Invalid Number
2nd Year Prior Amount Required
Invalid Number
1st Year Prior Amount Required
Invalid Number
1st Year Affiliation Amount Required
Invalid Number
2nd Year Affiliation Amount Required
Invalid Number
3rd Year Affiliation Amount Required
Invalid Number
Mil/Government
3rd Year Prior Amount Required
Invalid Number
2nd Year Prior Amount Required
Invalid Number
1st Year Prior Amount Required
Invalid Number
1st Year Affiliation Amount Required
Invalid Number
2nd Year Affiliation Amount Required
Invalid Number
3rd Year Affiliation Amount Required
Invalid Number
Total
Additional Investment Projection
Yellow Pages
3rd Year Prior Amount Required
Invalid Number
2nd Year Prior Amount Required
Invalid Number
1st Year Prior Amount Required
Invalid Number
1st Year Affiliation Amount Required
Invalid Number
2nd Year Affiliation Amount Required
Invalid Number
3rd Year Affiliation Amount Required
Invalid Number
Sales Staff
3rd Year Prior Amount Required
Invalid Number
2nd Year Prior Amount Required
Invalid Number
1st Year Prior Amount Required
Invalid Number
1st Year Affiliation Amount Required
Invalid Number
2nd Year Affiliation Amount Required
Invalid Number
3rd Year Affiliation Amount Required
Invalid Number
Additional Marketing
3rd Year Prior Amount Required
Invalid Number
2nd Year Prior Amount Required
Invalid Number
1st Year Prior Amount Required
Invalid Number
1st Year Affiliation Amount Required
Invalid Number
2nd Year Affiliation Amount Required
Invalid Number
3rd Year Affiliation Amount Required
Invalid Number
Equipment Purchase
3rd Year Prior Amount Required
Invalid Number
2nd Year Prior Amount Required
Invalid Number
3rd Year Prior Amount Required
Invalid Number
1st Year Affiliation Amount Required
Invalid Number
2nd Year Affiliation Amount Required
Invalid Number
3rd Year Affiliation Amount Required
Invalid Number
Painting/Refurbishing
3rd Year Prior Amount Required
Invalid Number
2nd Year Prior Amount Required
Invalid Number
1st Year Prior Amount Required
Invalid Number
1st Year Affiliation Amount Required
Invalid Number
2nd Year Affiliation Amount Required
Invalid Number
3rd Year Affiliation Amount Required
Invalid Number
Other
3rd Year Prior Amount Required
Invalid Number
2nd Year Prior Amount Required
Invalid Number
1st Year Prior Amount Required
Invalid Number
1st Year Affiliation Amount Required
Invalid Number
2nd Year Affiliation Amount Required
Invalid Number
3rd Year Affiliation Amount Required
Invalid Number
Total
Growth
Year 1
Year 2
Year 3
Year 4
Year 5
Average Growth
Revenue
Click Update to calculate Totals and Revenue Growth
The undersigned hereby authorizes Allied Van Lines, Inc.(AVL) to collect, use and disclose any personal information and banking information referenced in this Agency Application to assess the applicant's candidacy and to maintain the working relationship should the applicant be selected as an agent. The undersigned further authorizes AVL to investigate the veracity of statements contained in this Agency Application, as part of AVL's procedure for processing and assessing said applications. Any personal information will be handled in accordance with AVL's privacy policy, a copy of which can be found at www.Allied.com. The undersigned further agrees to hold harmless all persons and companies from whom AVL may seek, in good faith, information about the Undersigned Company and management thereof, which will assist AVL with respect to the application. The undersigned hereby makes and gives AVL and said person and companies full release and discharge to all damages, claims and injuries of any kind resulting from said disclosures so long as the disclosures are made in good faith and reasonably related to the agency application, and the purpose of the use thereof is solely related to the determination of fitness as an agent for AVL. The undersigned further understands that it has the right to make a written request within a reasonable period of time for a complete and accurate disclosure of additional information concerning the nature and scope of the investigation.
By signing below applicant certifies that all information contained in this application is accurate and complete to the best of his knowledge. Applicant further acknowledges that AVL will rely on the information in this application in deciding whether to offer an agency contract to applicant and that, therefore, should AVL determine that the information contained herein is materially incorrect or incomplete that Allied may reject this application or, if previously granted, may terminate applicant's agency contract with AVL. Finally, applicant acknowledges that the decision as to whether AVL approves this application is solely within its discretion.
The parties hereto have expressly agreed that this document and all ancillary agreements, documents or notices relating thereto be drafted solely in English. Les parties aux presentes ont expressement convenu que ce document et toute autre convention, document ou avis y afferent soit redige uniquement en anglais.
(*)Name of Applicant:
Name of Applicant Required
PLEASE SAVE AND PRINT A COPY OF THIS APPLICATION FOR YOUR OWN RECORDS BEFORE SUBMITTING.
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