Internal-Consortium-Form

DOT Agency*
FMCSA*

25% Drugs and 10% Alcohol
USCG*

Random rate 25% for drugs No Alcohol
FAA*

Random Rate Drug 25% and 10% Alcohol
PHMSA*

Random rate 50% drugs Alcohol N/A
FTA*

Random Rate 25% and 10% for Alcohol
FRA*

Random Rate 25% drug and 10% alcohol
FRA (MOW)*

Random Rate 50% and Alcohol 25%-Employee, volunteer or contractor for a railroad company
Membership Type*
- New Entry
- Add To Existing Pool
Payment Method*
Packages*
- Complete Compliance
- Consortium Only
- Consortium + Test
- Supervisor Training
- MVR Report
State Fees
*
Membership Term*
DER Name*
DER Phone*
Company Name*
Address
Street Address Address Line 2 City State ZIP Code
DER Email*

Donor Info*

Name	CDL Number	Phone	Zip	Covered Position

Additional Information*

Phone	Fax	Collection Fee