FORWARDING ASSIGNMENT FORM You may place an order for transport services by submitting the following form. The mandatory form fields are marked in green. In case of any doubts please contact us – our employees will be happy to assist you with exhaustive information. ORDERING PARTY Company name: Tax: City: Zip: Street address: Phone: Fax: Email: Contact person: CONTRACTOR EL-TRANS S.A. ul. Weteranów 100, 05-250 Radzymin tel. +48 22 786 70 61, fax: +48 22 786 62 01 e-mail: biuro@el-trans.com LOADING DATE AND PLACE Date: Day: …12345678910111213141516171819202122232425262728293031 Month: …010203040506070809101112 Year: …20152016201720182019202020212022202320242025 Hour: Leading ID: Company name: Phone: Fax: UNLOADING DATE AND PLACE Date: Day: …12345678910111213141516171819202122232425262728293031 Month: …010203040506070809101112 Year: …20152016201720182019202020212022202320242025 Hour: Leading ID: Company name: Phone: Fax: CARGO Product: Weight in Kg: Liters: UN number: ADR class: Packing group: Excise product: Other: ADDITIONAL REQUIREMENTS CONCEMING LOADING/UNLOADING Pump: Compressor: Adapters: OTHER Custom clearance: Payment form: Other: Send a copy to myself. I authorize the EL-TRANS company to process my data for marketing purposes.