ENROLLMENT IS PER DRIVER IN YOUR COMPANY NOT THE COMPANY BY ITSELF

DOT CONSORTIUM ENROLLMENT FORM

DER (Designated Employee Representative)

First Name

Last Name

Choose the following that describes you

Company Name

DER Contact Phone #

(Designated Employee Representative)

(###)

###

####

Registered DOT Number #

ENROLLMENT PLAN

Number of Drivers you want to enroll

Drivers that need enrollment

(Add driver full name, CDL # & State, DOB per line or you can send us a spreadsheet with the following information)

Effective Date

YYYY

Company Physical Address

(Cannot be a PO Box, must be the physical address registered for your DOT Company)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Is the mailing address same as the physical address?

(If not, provide below)

Yes

Mailing address if different from above

In order to finalize the enrollment, a payment must be made upfront for the enrollment.

(This fee must be paid upfront before we begin services)

I AGREE

Add valid card info to CREATE AN ACCOUNT

NAME ON CARD

CARD NUMBER

Expiration Date

YYYY

CVV

Billing Zip Code

Invoice option for testing

PAY UP FRONT (NO CREDIT CARD ON FILE)

INVOICE ME (MUST HAVE A VALID CARD ON FILE)

CHARGE CARD AUTOMATICALLY FOR ANY REQUESTED SERVICES