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.

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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#

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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