Delivery Receipt Ticket

DELIVERY RECEIPT TICKET

RECITALS

WHEREAS, Deliverer Name: certifies that the goods described in this Delivery Receipt Ticket were loaded and dispatched from the point of origin under the conditions stated below;

WHEREAS, Recipient Name: acknowledges receipt of such goods and accepts responsibility to inspect them at the time of delivery and to note any shortages or damages on this ticket;

WHEREAS, both parties agree that signature on this form constitutes binding acknowledgment of quantity, condition and delivery time except as expressly noted in the Exceptions section below.

PARTIES & DELIVERY INFORMATION

Ticket No.:    PO / Ref No.:    Delivery Date:

Delivery Time:    Carrier:    Vehicle/Truck No.:

Driver Name:    Driver Phone:

ITEMS DELIVERED (COUNT AND CONDITION)

CONDITION ON DELIVERY & EXCEPTIONS

Received in good order and condition:    Received with visible damage or shortage (see Exceptions below):

SCOPE OF WORK

PAYMENT TERMS

Amount Due for Delivery Services: $

Payment Schedule / Terms:

Late Fee: — applies to overdue balances until paid in full.

TERM AND TERMINATION

Effective Start Date:    Expected Completion / End Date:

Termination Notice Requirement: — either party may terminate for material breach if uncured within the notice period.

CONFIDENTIALITY

Each party shall maintain confidential all non-public business information disclosed in connection with the delivery and shall not disclose such information to any third party except as required by law or with the prior written consent of the disclosing party. This confidentiality obligation survives termination of this ticket for a period of two years.

GOVERNING LAW

This Delivery Receipt Ticket and any dispute arising out of or relating to it shall be governed by the laws of the State of , without regard to conflict of laws principles.

ENTIRE AGREEMENT

This document constitutes the entire agreement between the parties with respect to the delivery of the goods described herein and supersedes all prior agreements and understandings, whether written or oral. Any amendment must be made in writing and signed by both parties.

ACKNOWLEDGMENT

By signing below, Recipient acknowledges receipt of the items listed above, confirms that the items were inspected at delivery, and accepts responsibility for safekeeping from the time of signature except for those exceptions expressly noted on this ticket. Deliverer acknowledges that all items listed have been delivered to the location noted above in the quantities recorded, subject to the Exceptions section.

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