SR International Logistics, LLC



Request for Known Shipper Re-Verification

|Requested Inspection Date: | |  |

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|Name of Business: | |  |

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|Also doing business as: | |  |

|Name of person contacted: | |  |

|Title: | |  |

|Account number: | |  |

|Contract number: | |  |

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|Address Information: | | |

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|Address 1: | |  |

|Address 2: | |  |

|City: | |  |

|State/Province: | |  |

|Postal Code: | |  |

|Country: | |  |

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|Contact Information: | | |

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|Principal contact phone: | | |

|Facsimile number: | |  |

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|Requested By: | |  |

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|Air Carrier/Indirect Air Carrier: | |Columbia Logistics, Inc. (Charlotte) |

|Phone: | | (704) 329-3828 |

|Fax: | | (704) 329-3830 |

|E-mail: | |jorge@ |

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|IAC Number: | |EA 9711005 |

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|Signature of requesting party: | |  |

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