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Derby

By Andrew Horn | June 5, 2020

299 Seymour Ave
Derby, CT 6418

68 Division St
Derby, CT 6418

78 Pershing Dr
Derby, CT 6416

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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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