mrservices.capstonelogistics.comManaged Receiving - Provider Registration Form.

Provider Registration Form Already registered? Need help? Contact Help Desk @ MgdRecSupport@capstonelogistics.com . Please complete the registration form below to submit Appointments On Line for the Managed Receiving Application. Once submitted, your form will be reviewed for processing. Once approved, you will receive an email with a user name and password to begin making appointments. A user guide to the appointment system will be attached as well. All labels with dotted underlines provide "hover help". Simply move your mouse cursor over the label to see the help. * Red asterisk mark denotes a required field Login Information Email Address * Password * Verify Password * First Name * Last Name * Title Provider Information Provider Type Select One Carrier Vendor Vendor Arranged * Provider Name * Office Phone Extension Fax Number Mobile Phone Street Address Ste/Num/Etc. City * State / Province Alabama Alaska Alberta Arizona Arkansas British Columbia California California California California California California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Illinois Illinois Illinois Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Missouri Montana Nebraska Nevada New Brunswick New Hampshire New Jersey New Mexico New York Newfoundland North Carolina North Carolina North Dakota Northwest Territories Nova Scotia Ohio Oklahoma Ontario Oregon Pennsylvania Prince Edward Island Quebec Rhode Island Saskatchewan South Carolina South Dakota Tennessee Tennessee Texas Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Yukon * Postal Code * Acceptance of Terms I accept the Terms and...