Everdriven Drug and Alcohol Consortium Program

EverDriven
Membership Fee for Covered Services

Annual Membership Fee: $50.00

Pre-Employment Drug Test Required

Drug Screen Charge: $45.00

Driver / Monitor

Driver / Monitor Name
Driver / Monitor Name
First
Last
Member Mailing Address
Member Mailing Address
Include Apartment/Suite Number if Applicable
City
State/Province
Zip/Postal

Company Designated Employer Representative (D.E.R.)

D.E.R. Name
D.E.R. Name
First
Last
Reporting Method of Results
Total

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