4295 Harris Hill Road
Buffalo, New York 14221
716.276.2045  800.649.4939
Agency Application
To apply, please take a moment to fill-out the form below.
Company Information * Indicates Required Fields
Agent of Record*
Agency/Company Name*
Mailing Address*
City*
State/Province*
ZIP Code*
Physical/Street Address (if different from mailing)
City*
State/Province*
ZIP Code*
If corporation*, enter Federal ID Number

Contact Information
Telephone Numbers*  (Two contact numbers required)
Area Phone No. Ext. Type
E-mail Address*
Dispatcher(s):*
Dispatch Telephone*
Area Phone No. Ext. Type
Dispatch E-mail*

Personal Information
Home Address*
City*
State/Province*
ZIP Code*
Birthdate*   (MM/DD/YYYY)
Driver's License Number*
State of Issue*
Home Telephone*
Area Phone No. Ext. Type

* Q1. Where is your business going to be located?
(Home, office, etc.)
* Q2. What kind of Internet connection do you have?
(Dial-up, DSL, cable, etc.)
Q3. List any current or prior agency affiliations that you wish to tell us about:
* Q4. What type of freight do you move?
* Q5. What type of equipment do you use most?
* Q6. How much freight do you currently broker, in terms of loads per month?
* Q7. How much freight do you broker, in terms of sales revenue per month?
* Q8. What was your gross revenue last year?
* Q9. What is your current average gross profit margin (%)?
* Q10. What are you projecting your annual gross revenue will be when you join Extra Mile?
* Q11. How many loads do you project you will move the first month with Extra Mile?
* Q12. Why are you interested in joining Extra Mile Transportation?
* Q13. What can we do to make you successful in this new business venture?
* Q14. How did you find us?
Q15. Could you refer someone else? Please provide their name and contact information here:
(Extra Mile pays a generous bounty for agents signed by referral. Please provide referrer name and contact information.)
Security Check
Please enter the word you see into the space provided.
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