Chicago Maritime Group - Drug Test Only Request
Applicant Registration for USCG/DOT Drug Test Only Registration
Applicant Information
First Name *
Your answer
Last Name *
Your answer
E-mail Address *
Your answer
I hereby apply for a USCG compliant drug test. *
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 Fee
If I change my mind about this request and no drug tests have been ordered for or taken by me I will receive back any fees paid if they are requested in writing within 10 days of the date of this application. No refunds are given after a test has been ordered or taken.
The $60 drug test fee must be paid before test is scheduled
(A) I am taking a drug test only (No consortium membership) *
Select Yes or No
Return to the start page after submitting this application
You must pay for your selections prior to receiving any drug test or benefits
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