Quick Pay Authorization - Invoice & Proof of Delivery - Completed Quick Pay Authorization form (Comcheck page if applicable, or ACH form is applicable) - Signed Carrier Contract In order for Brock to release Quick Payment you will need to have provided the following to your broker: **Brock, LLC will not accept Quick Pay Forms that are not filled out completely.** 3 Quick Pay options Authorized Signature Via Postal Mail - 2% of payment Via ACH Check - 2% of payment (ACH form must be attached or if already on file with Brock – please note on file) Via Comcheck -2% of payment + $30 fee (Comcheck from must be filled out and attached) PRO # (Brock Pro Number) (mark one) Print Name Date Phone Number Address: (please note Federal Express does not deliver to P.O. Boxes) BROCK TRANSPORTATION LLC 333 N Canyons Pkwy Ste 221 Livermore CA 94551 Call: (925) 371-2184 Fax: (925) 371-7036
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Quick Pay Authorization
- Invoice & Proof of Delivery- Completed Quick Pay Authorization form (Comcheck page if applicable, or ACH form is applicable)- Signed Carrier Contract
In order for Brock to release Quick Payment you will need to have provided the following to your broker:
**Brock, LLC will not accept Quick Pay Forms that are not filled out completely.**
3 Quick Pay options
Authorized Signature
Via Postal Mail - 2% of payment
Via ACH Check - 2% of payment (ACH form must be attached or if already on file with Brock – please note on file)
Via Comcheck -2% of payment + $30 fee (Comcheck from must be filled out and attached)
PRO # (Brock Pro Number)
(mark one)
Print Name
Date
Phone Number
Address: (please note Federal Express does not deliver to P.O. Boxes)
BROCK TRANSPORTATION LLC333 N Canyons Pkwy Ste 221Livermore CA 94551Call: (925) 371-2184Fax: (925) 371-7036
AUTHORIZATION AGREEMENT AUTOMATIC DEPOSITS (ACH CREDITS)
I (we) hereby authorize Brock, LLC, hereina�er called COMPANY, to initiate credit entries to my (our) account indicated below at the financial institute named below, hereina�er called FINANCIAL INSTITUTION, I (we) acknowledge that the origination of ACH transactions to my (our) account must comply with the provisions of U.S. law.
This authority is to remain in full force and e�ect until COMPANY has received written notification from me (or either of us) of its termination in such time and manner as to a�ord COMPANY and FINANCIAL INSTITUTION a reasonable opportunity to act on it.
Financial Institution Name
PRO # (Brock Pro Number)
Routing Number
Account Number
Print Individual Name and Company Name
Signature Date
BROCK TRANSPORTATION LLC333 N Canyons Pkwy Ste 221Livermore CA 94551Call: (925) 371-2184Fax: (925) 371-7036
COMDATA
Fax the completed form to your broker at:
** Brock will not accept Comdata Forms that are not filled out completely **
Carrier - Authorized Signature
Total Agreed Rate:
2% Quick Pay fee:
Comcheck fee ($30.00):
Final Rate due to carrier at time of billing:
PRO # (Brock Pro Number - One Page for each Pro)
Carrier - Print Name
Driver's Name as shown on Driver’s License
City & State where advance is to be received (Not Mandatory)
Date
Authorization Code Confirmation Received
Phone Number
To be completed by Brock:
BROCK TRANSPORTATION LLC333 N Canyons Pkwy Ste 221Livermore CA 94551Call: (925) 371-2184Fax: (925) 371-7036
-30.00
CARRIER:
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