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2013 Online Membership Form

It’s Easy To Join

1 ) Fill In Member Form and “Press Submit Button”
2) Pay via PayPal

Note: If you only need to make a payment without filling out the form below, please click here

Directions

Please read and complete each part of this membership application.
Applications may be completed online, faxed, e-mailed, or mailed U.S. Post.

Membership costs $63.00

Enrollment covers costs of random tests for enrolled persons, regardless of the number of times each person is selected from January 1, 2013 until December 31, 2013.


Once you fill out this form, you will be prompted to pay for membership with a credit card via PayPal.

A pre-employment drug screen is required for any person joining a drug testing program unless he/she has been tested within the past 6 months, or has been subject to random testing for at least 60 days within the past 6 months. If you are not required to take a pre-employment test, please enclose original documentation with application. If you need a drug screen we will provide you with a collection site in your area, please fill out the application accordingly.

If you currently need a test, it is an additional $60.00.

2013 Membership Agreement

The Keys Consortium will provide each member: (a) A specimen collection site near the applicant’s residence. (b) Computer generated random selection of members. (c) Medical Review Officer (MRO) services. (d) Drug free workplace policy. (e) Record keeping of all positive test results for five years, and negative results for one year. (f) Membership cards. (e) Referral service to a counselor and (f) a letter confirming compliance.

Member Responsibilities

New membership or Renewal of your membership shall be deemed as consenting to the following agreement. Members must (a) properly follow random testing instructions. (b) Promptly notify Keys Consortium of any change in address, phone number employer change or membership status. (c) Follow all guidance provided by Keys Consortium. Members shall not hold Keys Consortium liable arising out of or in connection with a member's failure to comply with DOT policy or breech of this agreement. Failure to comply with provisions of this agreement will result in Coast Guard notification and possible termination from program.


To submit this form is to agree to acknowledge that I have read the membership agreement, and that I fully understand that violation of this policy will be grounds for immediate termination of my membership.

Fields in red are required


Membership Type:
Name:
Address:
City:
State:
Zip Code:
Home Phone:
Date of Birth (M/DD/YYYY)
E-mail Address
Confirm E-mail Address:
Are You a Captain or a CDL?:
Do You Need a Drug Test?:
   
Employer Name:
Employer Phone No.:
Alternate Contact Name:
Alternate Contact Phone No.
(Friend or Spouse):
   
Who's Paying For Your Membership?
   
Do you need any required Single Alcohol Tests?
(usually used for Post Accident or R/S)    
If yes, how many?
 
VESSEL INFORMATION
If you operate your own vessel please state if it is USCG Documented and/or State Registered and write the number below.


Document #

 

Comments:


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