MMG/URI Registration Form

Drug Test/Consortium Registration Form

Fill out the form carefully for registration
Client Name*

First NameLast Name
Company (If Maritime Related)
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mobile Number*
Client E-mail*
example@example.com
Position/Title*
Birth Date*

MonthDayYear
Options*
Within the last 6 months, have you had a DOT/USCG drug test, been a member of a consortium or in a maritime employer's random drug testing program? NOTE - If you cannot answer YES to this question you MUST take a drug test to enroll*

YESNO
Merchant Mariner Reference Number - REQUIRED if USCG Licensed
Additional Comments

Options - Payment is required in advance for any services*

Drug Test and 1 Year Consortium Membership Product Image

Drug Test and 1 Year Consortium MembershipThis is the only option for new enrollees unless you have had a DOT/USCG drug test within 120 days. This is a 5 Panel Urinalysis and 1 Year Random Drug Testing Program combination

$130.00 Quantity

Drug Test OnlyUSCG/DOT Compliant - 5 Panel Urinalysis

$70.00 Quantity

1 Year Consortium Membership Product Image

1 Year Consortium MembershipYou must have been in a random program for this option or a drug test is also required. 1 Year Random Drug Testing Program - New or Renewal

$70.00 Quantity

Total

$0.00

Payment Methods

Credit Card

Apple Pay

Google Pay

Should be Empty:

Drug Test/Consortium Registration Form

Payment Methods