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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.
   
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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