Consortium Company Update Form

Is the company an Owner/Operator or Multi-Employee?*
Mode of Consortium*
TeamCME Member Name*
Date*
MM slash DD slash YYYY
Provider Preferred Email
Consortium Company Name*
Consortium Company Phone
Consortium Company Address
Street Address City State ZIP Code
Designated Employer Representative (DER) Name
First Last
DER Phone
(If same as company phone, put n/a)
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

TeamCME Headquarters

First Name	Last Name	Date of Birth	License# & State	Specimen ID#

First Name	Last Name	Date of Birth	SSN	Specimen ID#

First Name	Last Name	License# & State

First Name	Last Name	SSN