Member Consortium Company Setup Form

Is the company an Owner/Operator or Multi-Employee?*
Mode of Company*
TeamCME Member Name*
Date*
MM slash DD slash YYYY
Provider Preferred Email*
Company Name*
Company Phone*
Company Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Designated Employer Representative (DER) Name*
First Last
DER Phone*
Total Number of Employees*
Please enter a number greater than or equal to 1.
For companies with 150+ employees please call to confirm pricing before submitting.
Please list ALL individuals participating in the consortium. 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
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#

TeamCME Headquarters

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

First Name	Last Name	Date of Birth	SSN	Specimen ID#