EDI Form Transmission Request

Required fields are in *BOLD
    Customer Information
  *Is this a Level 2 Logistics Request?:   Yes No
  *Company Name:
  *Address:
  *City:
*State:
*Zip:
  *Phone:
- - ext
Fax:
- -
  Website:
  Freight Payment Agency:
  Freight Management Company:
    Primary EDI Contact:
  *Name:
*Phone:
- - ext
  Title:
Fax:
- -
  *E-mail:
    Secondary EDI Contact:
  
Same as Primary Contact
  Name:
Phone:
- - ext
  Title:
Fax:
- -
  E-mail:
Accounts Payable Contact:
  
Same as Primary Contact
  Name:
Phone:
- - ext
  Title:
Fax:
- -
  E-mail:
Business Contact:
  
Same as Primary Contact
  Name:
Phone:
- - ext
  Title:
Fax:
- -
  E-mail:
Traffic Contact:
  
Same as Primary Contact
  Name:
Phone:
- - ext
  Title:
Fax:
- -
  E-mail:
Additional Contact:
  
Same as Primary Contact
  Name:
Phone:
- - ext
  Title:
Fax:
- -
  E-mail:
    Type of EDI billing required:
    Form: Please select desire document types
204 Load Tender / Pickup Request
210 Invoice
211 Bill of Lading
 
 
 
 
 
 
212 Trailer Manifest
214 Shipment Status
990 Response to a load tender
Other
Auto Accept?
Yes
No
 
 
Use 211 as pickup request?
Yes
No
Are you able to send reserve PRO numbers in the BOL06?
Yes
No
Comments:
 
 
Can you provide a 214 report card to Estes Express?
Yes
No
    Estes Account Numbers(s): (Get Account Number)
  
    Add more Account Numbers
    Addresses for locations requesting EDI:
  
    Add more Addresses
    Will reserved bills be used?
Yes
No
    Third Party Networks for EDI Applications (EDI VAN)
  
Kleinschmidt (Estes Express utilizes Kleinschmidt)
  
Other:
    Type of EDI Header:
    If FTP is preferred method of communication, provide the following:
Server Address:
Username:
Directory path:
Password:
    Header Information:
  Estes Express
  ISA Qualified:
02
  ISA ID:
EXLA
  SCAC:
EXLA
  Production BG01(Password):
Test BG01(Password):
  Production BG03(Receiver ID):
Test BG03(Receiver ID):
  Production ISA Qualifier:
Test ISA Qualifier:
  Production ISA Receiver ID:
Test ISA Receiver ID:
  Production GS ID:
Test GS ID:
    TDCC/ANSI Version: 4010, 4030 etc...
  
    Person Completing Form:
  
Same as Primary Contact
  Name:
  Phone:
- - ext
Select to send a copy of this request to your e-mail address