FAIL (the browser should render some flash content, not this).

New customers, complete this form to receive 10% off the first 2 weeks of service.
Plus, lock in your rate for 6 months regardless of increase in fuel cost.

Company Information
Company Name:
Billing Street:
City:  State: Zip:
Billing Phone:
Contact Information
Contact Name: Contact Phone:
Email: Fax:
Company Profile:

Typical Shipment Distance

0-50 Miles 51-100 Miles Over 100 Miles
Vehicle Use: (choose which option most represents your need for each vehicle)
Cargo Van

16' Box Truck
24' Dock High Truck
Frequency of Deliveries times per
Type of Cargo
Do you have shipments
over 200 miles
(if yes please provide details below of frequency, vehicle needed, and approx. mileage)
  Details and Additional Information:
Copyright 2008 © Lighthouse Delivery.
All rights reserved.