Store / Hub Location
Counter Agent / Clerk Name
Pickup Station / Locker Bay ID
Date of Collection
Time of Collection
Order / Reservation Number
Tracking / Package Barcode ID
Customer Name (on Order)
Number of Packages Picked Up
1
2
3
Other:
Complete verification prior to releasing packages from holding counter:
A. Pickup Representative Type
Primary Account Holder: Customer named on order.
Designated Proxy / Agent: Family member, courier, or friend picking up on behalf of customer.
Third-Party Courier: (e.g., Uber Direct, DoorDash, local courier agent).
B. Identity & Authentication Checks
Government Photo ID Verified: Driver's License / Passport / State ID presented.
ID Type
Last 4 Digits
Barcode / Pickup QR Code Scanned: Scanned from mobile app or email confirmation.
Pickup Code / PIN Verified: System authorization code matched.
Verification Parameter | Pass | Fail | N/A | ||
|---|---|---|---|---|---|
A | B | C | D | ||
1 | 1. Packaging is intact, undamaged, and correctly sealed. | ||||
2 | 2. Customer inspected outer packaging in presence of counter staff. | ||||
3 | 3. Age-restricted item check completed (if applicable, 21+ ID verified). | ||||
4 | 4. Payment at counter finalized (COD / outstanding balance paid). |
Mark the final outcome of the counter interaction:
Full Collection: All items/parcels successfully handed over.
Partial Collection: Customer collected part of order; remaining items held in storage.
Refused at Counter: Customer inspected parcel and rejected it (e.g., wrong item, damaged).
Verification Failed: Customer could not produce valid ID or pickup barcode; release denied.
Reason
(Record any payment discrepancies, customer complaints, damaged box observations, or proxy authorization notes)
Counter Agent Attestation:
"I confirm that I verified the collecting party's identification credentials and released the authorized parcel(s) listed above."
Agent Signature
Customer / Collector Attestation:
"I acknowledge receipt of the package(s) listed on this form in good condition and confirm that I am authorized to take possession of this order."
Collector Signature
Time Signed
Form Template Insights
Please remove this form template insights section before publishing.
While delivery forms protect couriers on the road and intake forms shield receiving docks, the Customer Pickup & Counter Collection Log protects retail stores, click-and-collect centers, and fulfillment hubs. It acts as the final operational gateway in "buy online, pick up in-store" (BOPIS) and over-the-counter (OTC) workflows, ensuring that orders leave the store only with authorized individuals.
Mandatory Questions Recommendation
Please remove this mandatory questions recommendation section before publishing.
The five mandatory fields for the Customer Pickup & Counter Collection Log Form, along with the operational and financial reasons why they are non-negotiable, are detailed below.
To configure an element, select it on the form.