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Middleburg Heights

By Andrew Horn | June 9, 2020

18660 Bagley Rd
Middleburg Heights, OH 44130

7155 Pearl Rd
Middleburg Heights, OH 44130

7155 Pearl Road
Middleburg Heights, OH 44130

7271 Engle Road
Middleburg Heights, OH 44130

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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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Consortium Type: Check 1 box only, Designated Employee Representative (DER) information is required*
*
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Owner Operator:*
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Driver SSN or Employee ID:*
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* DOT pre-employment drug test must be completed before driver is added to random pool.

Step 2: Choose Enrollment Package:
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- Basic Package ($100)
  - 1-Year Enrollment in Randoms
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  - Paper CCFs or Electronic CCFs
  - $60 Drug Test / $50 Breath Alcohol
- Compliance Package ($300)
  All Benefits of Basic Package plus:
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  - 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)
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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.
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