Dot Consortium / Company with 2 or more Drivers

Company Name: *

Contact Name: *

Address 1: *

Address 2: (optional)

City: *

State: *

Zip: *

Phone: *

Fax: (optional)

Cell Phone: (optional)

E-mail Address: *

Company DOT Name: (optional) FMCSA FAA FRA FTA PHMSA USCG

DOT # (optional)

Consortium Type: Check 1 box only, Designated Employee Representative (DER) information is required * Company with 2 or more Drivers to enroll in Consortium Pool

DER Name: *

DER Phone #: *

DER Cell #: *

DER E-mail: *

Choose Enrollment Package: (optional) 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 (optional) 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

Payment: * Card Holder Signature I agree I have read and agree to the website Terms and Conditions I have read and agree to the website Additional Products Terms