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Boulder

By Andrew Horn | June 5, 2020

2798 Arapahoe Avenue
Boulder, CO 80302

1690 30th St
Boulder, CO 80301

737 29th Street
Boulder, CO 80303

3300 28th St
Boulder, CO 80301

4800 Baseline Rd
Boulder, CO 80303

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DOT Consortium Program Enrollment Form

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Company Name:*
Step 1: Contact Information:
Contact Name:*
Address 1:*
Address 2:
City:*
State:*
Zip:*
Phone:*
Fax:
Cell Phone:
E-mail Address:*
Company DOT Name:
DOT #
Consortium Type: Check 1 box only, Designated Employee Representative (DER) information is required*
*
- Owner Operator
- Company with 2 or more Drivers to enroll in Consortium Pool
- Company with 100 or more Drivers for a Stand-Alone Random Pool
Owner Operator:*
Driver Name:*
Driver SSN or Employee ID:*
DER Name:*
DER Phone #:*
DER Cell #:*
DER E-mail:*
* DOT pre-employment drug test must be completed before driver is added to random pool.

Step 2: Choose Enrollment Package:
*
- Basic Package ($100)
  - 1-Year Enrollment in Randoms
  - Certification of Enrollment
  - Paper CCFs or Electronic CCFs
  - $60 Drug Test / $50 Breath Alcohol
- Compliance Package ($300)
  All Benefits of Basic Package plus:
  - 2 Free Drug Tests
  - DOT Policy
  - Required Supervisor Training
  - Part 40.25 Form (Required for all drivers)
Optional Add On
*
- 2 Additional Years of Enrollment ($100)
- Part 40.25 Form ($25)
- Supervisor Training ($50/each)
- Paper Copies of 49 CFR Part 40 & 382 ($25)
- DOT Policy ($75)
- DOT Pre-Employment Drug Test ($60)
- No Additional Add-Ons = $0.00
All fees must be remitted with this form.
Add all columns on front and back on this form.
Step 3: Payment:
Please Proceed to the shop page to purchase your desired package. Your application will not be processed without purchase.
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