If your company is not currently enrolled, please go to new membership application

Directions: Please read and complete each part of this form.

Applications with credit cards can be submitted online via secure server. Check payments must be sent regular mail.

If you are adding ANY crew members, you must comply with the DOT regulation concerning a background check.

"*" indicates required fields

Account Number*

Company*

Contact Person*

Email*

Phone*

Address

Address Line 2

City

State*

Zip

Crew Members

Crewmembers to Add – You must enter a Social Security Number with dashes and a name, otherwise this can not be processed

If you mark a crewmembers as exempt, you must provide us with a negative DOT test dated within the last 6 months or a letter of compliance, on Company letterhead, dated within the last 30 days. Please email to info@drugfreevessel.com

Note: Maritime ID Cards will be issued upon receipt of documentation of pre-employment status.

Enter the total number of crew you want to add in the box – “Number of crew members to Add”

Number of Crew Members to Add*

Enter the number of crew who need a test in the box “Crew Members Who Need a Test” and enter the number of crew who do not need a test in the box “Crew Members Who are Exempt”. Drop Down boxes will appear below the line and you will enter the information on those lines.

Crew Members Who Need a Test*

Crew Members Who Are Exempt*

Add Crew Members That Need a Test*

Name

Social Security

Date of Birth

Pre-Employment

License Status

Add Crew Members That Are Exempt*

Name

Social Security

Date of Birth

Pre-Employment

License Status

Number of Crew Members to Delete*

Crewmembers to Delete*

Name

Social Security or MID Number

Note: For every person you delete from your program, you can add one above for no enrollment fee

Note: Maritime ID Cards will be issued upon receipt of documentation of pre-employment status.

Membership Fee

Captains and Crewmembers Added

(from above) $75 per person. $85 in AK, HI, PR, VI. For Saipan and Guam $100 per person. Does not include any discounts.

Price:

Quantity

Captains and Crewmembers Deleted

(from above)

Price:

Quantity

Pre-employment tests

$60 per test

Price:

Quantity

M-PAKs

$20 per kit (covers one captain/crewmember) (Mailed out within 2-3 weeks unless FEDEX is requested) See here for regulation

Price:

Quantity

Shipping Method*

(Please specify Priority or Overnight shipping)

Priority USPS Mail

Fed Ex Overnight Mon-Fri

Fed Ex Sat Delivery

Payment Information

Total

Payment Method*

Visa

Mastercard

Amex

No Payment

Cardholder Name*

Credit Card Number*

Expires*

CVV*

Any special instructions when processing your application?