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Erie

By pwsadmin | July 21, 2020

1526 B Peach Street
Erie, PA 16501

2020 E 38th St
Erie, PA 16510

2501 W 12th St
Erie, PA 16505

3010 W Lake Rd
Erie, PA 16505

3315 Liberty St
Erie, PA 16508

350 E Bayfront Pkwy
Erie, PA 16507

4108 Zuck Road
Erie, PA 16506

4247 West Ridge Road
Erie, PA 16506

4916 Buffalo Rd
Erie, PA 16510

5039 Peach St
Erie, PA 16509

7200 Peach Street
Erie, PA 16509

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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:*
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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:
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