Everdriven Drug and Alcohol Consortium Program

EverDriven

Date

Membership Fee for Covered Services

Annual Membership Fee: $50.00

Pre-Employment Drug Test Required

Drug Screen Charge: $45.00

Driver / Monitor Name

First

Last

Driver's License Number and State for Driver / Monitor

Last 5 Digits of Driver / Monitor Social Security Number

Service Provider / Company Name

Member Mailing Address

Include Apartment/Suite Number if Applicable

City

State/Province

Zip/Postal

Member Phone Number

Member Fax Number

Member Email

D.E.R. Name

First

Last

D.E.R. Title

Reporting Method of Results

E-Mailed

Mailed only

Total

EverDriven