ADD TO OR REMOVE FROM EXISTING CONSORTIUM (DOT) RANDOM ENROLLMENT

If we are currently coordinating your periodic random DOT consortium and need to add or remove an individual(s) to the existing consortium, please fill out the form below.

COMPANY NAME

Requester Name

First Name

Last Name

Contact Phone # :

(###)

###

####

If you are replacing someone into the random, both sections need to be filled out

Keep in mind that the replacement will be valid until the previous enrollment date expires.

(ADD) Driver/ individual (+ $5)

*Full name, CDL # & state, DOB (One individual per line)

(REMOVE) Employee(s)/individual(s) below***

Names of the driver(s) who need to be removed

*Full name, CDL # & state (One individual per line)

PAYMENT OPTION

Invoice me I have an account with a card on file

Pay invoice now, I do not have an account

Using Credit to remove and add driver