Quality Consortium Services

Member

Company

Company Name: *

Company DOT Number:

Testing Authority: *

Name of person making this request:*

Email: *

Member/Employee

First Name: *

Last Name: *

ID / License Number: *

CDL state of issue:

Do you need to order a pre-employment drug test ? * Yes - $65
No - I have test results within the last 30 days

Drug Test Requirements

I have access to a recent negative DOT drug test for the listed employee (within the last 30 days). I can produce a copy of the results in the event of a DOT audit.

A negative pre-employment DOT drug test will be obtained before the listed employee is involved in a safety sensitive role.

Employee Phone Number: *

Zip (to locate nearest collection site): *

Notes:

Clearinghouse

Allow Consortium to query FMCSA Clearinghouse for this driver?

Yes

You must have an account setup with the Clearinghouse and have token queries available for use. Quality Consortium Services must be listed as your TPA in the Clearinghouse.

State of Issue: *

Member Date Of Birth: *

Billing Information

Credit or debit card

Annual Membership

$15/year

I have read the Terms of Service and I am authorized to act on behalf of my company

I agree

I acknowledge that membership in the program will automatically renew until I cancel service

I agree