Drug & Alcohol Consortium Intake
Business Name
*
USDOT Number
*
Owner Name
*
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Business Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How many CDL holders?
*
Driver Name (If Different From Owner)
First Name
Last Name
Driver Email (If Different From Owner)
example@example.com
Driver Phone Number (If Different From Owner)
Please enter a valid phone number.
Last 4 of Driver SSN
Upload a front and back copy of CDL. (If unable to, send a copy of CDL to admin@jm5logistics.com)
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Do you currently have a DOT Drug & Alcohol policy in place?
*
Yes
No
Do you need supervisor training for reasonable suspicion?
Yes
No
Not Sure
Best method of contact to discuss your needs.
*
Email
Phone
I agree to purchase additional drug screenings which are not included in my company's initial enrollment such as random, post accident, reasonable suspicion, RTD or follow-up screening as needed. ($100 Each)
*
YES
NO
Please keep in mind all enrollments are on an annual basis. Carrier is responsible for renewing consortium enrollment on or before enrollment anniversary. Carrier will be reminded via email, text or call prior to expiration.
*
I Understand
I will schedule an intake call immediately following the submission of this form. Availability will populate after form submission.
*
I Understand
My Products
*
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Annual Drug & Alcohol Consortium Enrollment
$
375.00
Credit Card
Submit
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