MyMidland Setup Request Form

First Name

Last Name

Email Address

Confirm your Email Address

Phone Number

Account Type

Transport

Courier

Both

Account Number(s)

SHIPPER LOCATION DETAILS

Company Name

Street Address

City

Province

Postal Code

Do you require any additional users to be setup to ship from this location?

Yes

No

How many additional users are required?

ADDITIONAL USER 1

First Name (Additional User 1)

Last Name (Additional User 1)

Email Address (Additional User 1)

ADDITIONAL USER 2

First Name (Additional User 2)

Last Name (Additional User 2)

Email Address (Additional User 2)

ADDITIONAL USER 3

First Name (Additional User 3)

Last Name (Additional User 3)

Email Address (Additional User 3)

ADDITIONAL USER 4

First Name (Additional user 4)

Last Name (Additional user 4)

Email Address (Additional user 4)

ADDITIONAL USER 5

First Name (Additional User 5)

Last Name (Additional User 5)

Email Address (Additional user 5)

Do you have additional shipping locations to be set up for MyMidland?

Yes

No

Please note that only one shipping location can be set up per form submission. To set up an additional shipping location, please complete another form after submitting the current.

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MyMidland Setup Request Form

User Information