Maritime Consortium, Inc. Form for Adding or Deleting Captains or

Crew from your Maritime Membership

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


Directions: Please read and complete each part of this form.
You can fill this form out on line in your browser, or save to your hard disk.
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.


Company:
Account Number
Price Code
Contact Person:

Phone:
E-mail:
State:
Fax:
Above fields are required for proper identification

Crewmembers to Add

NAME

Social Security

Date of Birth

Pre-Employment
(check one)


License Status: Licensed Unlicensed

Needs Test
Exempt
Quick Crew Switch

Crewmembers to Delete

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.

Enrollment Fee:

Description

Number

Cost

Amount

1. Captains and Crewmembers Added (from above)



2. Captains and Crewmembers Deleted (from above)


3. NET New Enrollments (part 1 minus 2)


$70 per person*


4. Pre-employment tests (including Quick Crew Switch)


$60 per test


5. M-PAKs (per employee) see regulation here

$15 per person


6. Shipping Method
(Please specify Priority or Overnight shipping)

Priority USPS Mail (no charge)
Fed Ex Overnight ($35)
Fed Ex Sat Delivery ($45)


TOTAL


Payment: VISA MC AMEX

Credit Card Number

Expires

C V V

Cardholder Name

*$80 in AK, HI, PR, VI (for Saipan and Guam $95 per person)
does not include any discounts

Any special instructions when processing your application?

or by mail to

PO Box 4070 • Annapolis, MD 21403-6070
Phone: 800-775-6985 • Fax 800-764-2350 • Email: membership@drugfreevessel.com

Street Address (for overnight only):
409 Chester Ave Ste 102 • Annapolis, MD 21403

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