Chicago Maritime Group - Individual Enrollment
Applicant Registration for USCG/DOT Drug Testing Program
Applicant Information
First Name *
Your answer
Last Name *
Your answer
E-mail Address *
Your answer
Membership *
I hereby apply for membership in the Chicago Maritime Group - for USCG compliant random selection drug & alcohol testing.
Required
Company Name or Current Marine Employer
(If none, leave blank)
Your answer
Cell Phone Number *
Your answer
Alt. Phone Number
Your answer
Mariner ID # *
USCG Reference Number From Your MMC (If none enter last 4 digits of Social Sec No)
Your answer
Date of Birth MM/DD/YYYY *
Your answer
Address *
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
I am a:
Drug Testing Administrator
(Person to receive all correspondence at your current marine employer) If you are a freelance captain or crewmember leave blank
First Name
Your answer
Last Name
Your answer
Who Referred You?
Your answer
Membership Fee (If joining the consortium)
(If Applying for Consortium Membership) I understand, that by joining this group and not refusing to be tested when selected, I meet the necessary requirements as listed in 46 CFR Part 16, & 49 CFR Part 40 for drug and alcohol testing for DOT & USCG programs. This program will place me in full compliance with applicable federal drug testing laws. I further understand that continuous membership in the group will require an annual payment of the membership fee before my expiration date each year. Current membership and testing fees may be found on the member website. All fees are subject to change.

If I change my mind about joining this group and no drug tests have been ordered for or taken by me I will receive back any membership fees paid if they are requested in writing within 10 days of the date of this application. I further understand that I may request removal of my name from the group for any reason, at any time, by notifying Chicago Maritime Group in writing, or by not renewing my membership by the expiration date each year. No refunds are given for voluntary disenrollment after the 10 day period.

The $60 per person annual membership fee must be paid before receiving any benefits. Please answer the following questions:
(A) I have not had a drug test... *
Select Yes or No - (A) I have not had a drug test within the past six months and have NOT been a member of another drug testing program or worked for another marine employer. I need you to send me for one, so I am including an additional $60 for my pre-employment drug test. (Initial alcohol tests not needed.)
(B) I have taken a drug test... *
Select Yes or No - (B) I have taken a drug test in the past six months so a pre-employment test is not needed. I am submitting a copy of the test results signed by a Medical Review Officer (MRO).
(C) I was a member of another random drug testing program... *
Select Yes or No - (C) I was a member of another random drug testing program during the immediate previous six or more months. I am submitting proof of my membership in the former group with this application.  Applicant must call them for a letter meeting USCG/DOT requirements
I am sending documents proving item "B" or "C" above.
Select Yes or No - I am sending via email to: info@chicagomaritimegroup.com the documents proving item "B" or "C" above.
Return to the start page after submitting this application
You must pay for your selections prior to receiving any drug test or benefits.
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service