M2Z Compliance Solutions
A Division of M2Z Holdings, LLC
PREFERRED SAP NETWORK
Provider Enrollment Form
Join the M2Z Preferred SAP Network and receive client referrals directly from our team. We work with DOT-prohibited owner-operators, CDL drivers through the full Return-to-Duty process and refer them to qualified SAPs in our network. This form takes about 2 minutes to complete.
SECTION 1 — CONTACT INFORMATION
Full Name
Business / Practice Name If different from your name
Phone
Format: (000) 000-0000.
Email
example@example.com
City & State Primary location where you conduct evaluations
Website or Booking Link Optional
SECTION 2 - YOUR SERVICES
How do you meet with clients?
In-Person
Telehealth / Virtual
Both
Which DOT modes do you serve?
FMCSA (CDL / Trucking)
FAA (Aviation)
FTA (Transit)
FRA (Railroad)
Other
Which RTD steps do you handle?
Initial SAP Evaluation
Education / Treatment Referral
Follow-Up Evaluation
RTD Recommendation
Follow-Up Testing Plan
Initial Evaluation Fee
Typical Report Turnaround Business days to written report
SECTION 3 - AVAILABILITY
Days available:
Mon
Tue
Wed
Thu
Fri
Sat
Sun
M2Z Compliance Solutions | info@m2zcompliance.com | Suwanee, Georgia
Page 1
Back
Next
M2Z Compliance Solutions
A Division of M2Z Holdings, LLC
PREFERRED SAP NETWORK
Provider Enrollment Form
Wait Time for New Clients Avg. days from referral to first slot
Same-Week Appointments? Yes/No/Sometimes
SECTION 4 — SIGN & SUBMIT
By signing below I confirm that:
I am a qualified SAP per 49 CFR Part 40
I hold a current professional license
I have no active disciplinary actions or sanctions
I consent to M2Z contacting me with referrals
I certify the information above is accurate. Inclusion in the network does not create an employment relationship with M2Z.
Printed Name
Date MM/DD/YYYY
-
Month
-
Day
Year
Date
Signature
SUBMIT THIS FORM
Email to:
info@m2zcompliance.com
Online at:
www.m2zcompliance.com
FOR OFFICE USE ONLY
Date Received:
Reviewed By:
Approved
Pending
Denied
M2Z Compliance Solutions | info@m2zcompliance.com | Suwanee, Georgia
Page 2
Preview PDF
Submit
Should be Empty: