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: