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northern Gas Transport, Inc.

Proof of Delivery Request Form

We are be pleased to provide you with a rate quote for your transportation needs. Please complete the information request below and submit. We will respond in a timely manner via your choice of email, fax or telephone. Thank you and we look forward to meeting all your transportation needs.

Company Name
First Name	Last Name
Phone	Fax Number
Email Address
*Preferred Contact*	Telephone Fax Email

Type of Product (check one)

Propane
Heating Oil
Gasoline
Heavy Oil

Flatbed

Van

Date of Delivery mm/dd/yy

Load/Release #

Bill of Lading #

Origin	City		State
Destination	City		State

Remarks