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

Service Provider / Company Name

Service Provider Fax Number

Service Provider Mailing Address

Include Apartment/Suite Number if Applicable

City

State/Province

Zip/Postal

D.E.R. Name

First

Last

D.E.R. Title

D.E.R. Phone Number

D.E.R. Email

Employee First & Last Name

First

Last

Employee Driver's License Number & State

Employee Phone Number

Employee Zipcode

Last 5 Digits of Employee Driver / Monitor Social Security Number

Total

EverDriven