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Cuyahoga Falls

By Andrew Horn | June 9, 2020

111 Stow Ave
Cuyahoga Falls, OH 44221

1860 State Road
Cuyahoga Falls, OH 44223

462 Howe Avenue
Cuyahoga Falls, OH 44221

654 Portage Trail
Cuyahoga Falls, OH 44221

654 Portage Trl
Cuyahoga Falls, OH 44221

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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:
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State:*
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Company DOT Name:
DOT #
Consortium Type: Check 1 box only, Designated Employee Representative (DER) information is required*
*
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- Company with 100 or more Drivers for a Stand-Alone Random Pool
Owner Operator:*
Driver Name:*
Driver SSN or Employee ID:*
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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)
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- 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:
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