Consortium Set-Up for Members "*" indicates required fields TeamCME Member Name* First Last TeamCME Member Email* Is the company an Owner/Operator or Multi-Employee?*Select OneOwner/OperatorMulti-EmployeeMode of Company*Select OneFMCSANon-DOTFAAFTAPHMSAUSCGCompany Participation Start Date* MM slash DD slash YYYY The chosen start date cannot be prior to the completion of this form.Company Name* Company Email* Company Phone*Company Address* Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Designated Employer Representative (DER) Name* First Last DER Phone*Total Number of Employees*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.comConsortium Participants*To add participants, select the plus icon to the left of the Specimen ID field.First NameLast NameDate of BirthLicense# & StateSpecimen ID#Consortium Participants*To add participants, select the plus icon to the right of the Specimen ID field.First NameLast NameDate of BirthSSNSpecimen ID# Add Remove
