Consortium Company Update Form

"*" indicates required fields

Is the company an Owner/Operator or Multi-Employee?*

Mode of Consortium*

TeamCME Member Name*

Provider Preferred Email

Date*

Consortium Company Name*

Consortium Company Phone

Consortium Company Address

Street Address City State ZIP Code

Designated Employer Representative (DER) Name

First Last

DER Phone

Adding and/or Removing Drivers*

Please select all that apply.

I am adding employees to this company.

I am removing employees from this company.

I am making a DER/Company address update.

I don't need to add or remove any employees.

List each driver being added to the company consortium list.

If you have an enrollment drug test from within the last 30 days (not preformed on a TeamCME CCF) or proof of enrollment in a prior consortium from within the last 30 days, please email it to consortium@teamcme.com and mark "N/A" in the Specimen ID# field.

Add the Following Consortium Participants*

First Name

Last Name

Date of Birth

License# & State

Specimen ID#

Add the Following Consortium Participants*

First Name

Last Name

Date of Birth

SSN

Specimen ID#

List each driver being removed from the company consortium list.

Remove the following Consortium Participants*

First Name

Last Name

License# & State

Remove the following Consortium Participants*

First Name

Last Name

SSN