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Evansville

By Andrew Horn | June 8, 2020

100 S. Rosenberger Ave
Evansville, IN 47712

1200 Professional Blvd
Evansville, IN 47714

14020 Old State Road
Evansville, IN 47725

206 N. First Ave
Evansville, IN 47710

206 North First Avenue
Evansville, IN 47710

2512 Waterbridge Way
Evansville, IN 47710

2532 Waterbridge Way
Evansville, IN 47710

350 W Columbia St
Evansville, IN 47710

4925 Hitch And Peters Road
Evansville, IN 47711

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Sacramento, CA 95834

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DOT Consortium Program Enrollment Form

Step 1 of 2

50%

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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- I have read and agree to the website Additional Products Terms

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