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TeamCME

Consortium Set-Up for Members

"*" indicates required fields

TeamCME Member Name*
MM slash DD slash YYYY
The chosen start date cannot be prior to the completion of this form.
Company Address*
Designated Employer Representative (DER) Name*
For companies with 150+ employees please call to confirm pricing before submitting.
Please enter a number greater than or equal to 1.
&nbsp &nbsp
Please list ALL individuals participating in the consortium. If you have an enrollment drug test from within the last 30 days (not performed 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
Consortium Participants*
To add participants, select the plus icon to the left of the Specimen ID field.
First Name
Last Name
Date of Birth
License# & State
Specimen ID#
 
Consortium Participants*
To add participants, select the plus icon to the right of the Specimen ID field.
First Name
Last Name
Date of Birth
SSN
Specimen ID#
 
DOT Medical Examiners > Member Consortium Company Setup Form

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Pendleton, OR 97801
Phone: (541) 276-6032
contact@teamcme.com

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