PUC Consortium Sign-Up Step 1

Thank you for choosing National Safety Compliance, Inc. Small Business Consortium Drug and Alcohol Testing Program.
Please complete the following information worksheet.

	Login Information
Email:
Password:

Repeat Password:

	Company Information
Company Name:
Company Address:
City:
State:	Please select Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Federated States of Micronesia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming
Zip:
Phone:	(123) 123-1234
Fax:	(123) 123-1234
	Designated Employer Representative (DER)
DER First Name:
DER Last Name:
DER Email:

DER Email Repeat:

U.S. DOT #:
CA #: (if applicable)
PUC# / PSG#: (if applicable)
	Drivers
How many drivers are you enrolling?	1 2 3 4 5 6 7 8 9 10

Driver #1 Name:
Driver #1 SSN:
Driver #1 Commercial Driver License(CDL)#:
Driver #1 Enrollment Date:	11/21/2024

Driver #2 Name:
Driver #2 SSN:
Driver #2 Commercial Driver License(CDL)#:
Driver #2 Enrollment Date:	11/21/2024

Driver #3 Name:
Driver #3 SSN:
Driver #3 Commercial Driver License(CDL)#:
Driver #3 Enrollment Date:	11/21/2024

Driver #4 Name:
Driver #4 SSN:
Driver #4 Commercial Driver License(CDL)#:
Driver #4 Enrollment Date:	11/21/2024

Driver #5 Name:
Driver #5 SSN:
Driver #5 Commercial Driver License(CDL)#:
Driver #5 Enrollment Date:	11/21/2024

Driver #6 Name:
Driver #6 SSN:
Driver #6 Commercial Driver License(CDL)#:
Driver #6 Enrollment Date:	11/21/2024

Driver #7 Name:
Driver #7 SSN:
Driver #7 Commercial Driver License(CDL)#:
Driver #7 Enrollment Date:	11/21/2024

Driver #8 Name:
Driver #8 SSN:
Driver #8 Commercial Driver License(CDL)#:
Driver #8 Enrollment Date:	11/21/2024

Driver #9 Name:
Driver #9 SSN:
Driver #9 Commercial Driver License(CDL)#:
Driver #9 Enrollment Date:	11/21/2024

Driver #10 Name:
Driver #10 SSN:
Driver #10 Commercial Driver License(CDL)#:
Driver #10 Enrollment Date:	11/21/2024

I'm an Owner-Operator:
	Shipping Information
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Recipient Name:
Company Address:
City:
State:	Please select Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Federated States of Micronesia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming
Zip:
Phone:

	Credit Card Billing Information
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Cardholder Name:
Address:
City:
State:	Please select Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Federated States of Micronesia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming
Zip:
Phone:

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