Maritime Consortium, Inc. Membership Application

This application may be submitted online using our secure form below, or by printing it out to mail or fax to Maritime.

Company:

Contact:

Address:

City:
State:
Zip:
Phone:
Fax:
E-mail:
VESSEL IDs (see here for regulation)

Important: if you are a sole-operator please click here for a notice.

Company Type:

Please Check all Months of Operation:

Where did you hear about The Maritime Consortium, Inc.?

If "other," please describe:

Directions: Provide information below for each captain, crewmember and deckhand who serves aboard the vessel. Please make copies of this form to list additional persons or add employees later. Be sure to list all persons who serve aboard a vessel and affect its safety, per the Coast Guard Regulation.

NAME

Social Security

Date of Birth

Pre-Employment
(check one)

License Status

Needs Test
Exempt

Licensed
Unlicensed

 

Membership Fee:

Description

Number

Cost

Amount

Enrollments in the Maritime Consortium


$65 per person*

Pre-employment tests


$55 per test


M-PAKs See here for regulation
$15 per employee

Shipping Method

(Please specify Priority or Overnight shipping)

Priority USPS Mail
(no charge)
Fed Ex Overnight
Mon-Fri ($25)
Fed Ex Sat Delivery
($35)


TOTAL


*$75 in AK, HI, PR, VI (for Saipan and Guam $90 per person)
does not include any discounts

Payment: VISA MC AMEX
Check (must accompany application)

Credit Card Number
ex: 1111222233334444 (no spaces)

Expires ex: 01/09

C V V

Cardholder Name

 

I agree to the Consortium Membership Agreement. (printed below)

Any special instructions when processing your application?




Maritime Membership Services include:

A. Testing Services
For the term that begins the date this application is received by The Maritime Consortium, Inc. (Maritime), to December 31, 2018, Maritime will act as employer’s (Member Company) intermediary (as provided in 40.345) and will provide the Member Company: (1) A specimen collection site within thirty miles of Company’s registered office whenever possible; (2) Overnight express shipment of specimen to be tested at a SAMHSA approved testing laboratory; (3) Laboratory testing utilizing state of the art testing procedures including EMIT screening, GC/MS confirmations, proficiency testing, quality control blind samples of 1 percent, on-site inspections, adulteration checks, and 72 hour reporting of results; (4) Computer generated random selection of employees by Maritime; (5)Notification of Member Company’s Designated Employer Representative will be in writing when employee/contractor is selected for a drug test; (6) Serious Marine Incident (SMI) testing when the available M-Pak kits are obtained and used according to included instruction for required drug and alcohol tests; (7) For cause testing; (8) pre-employment testing available as explained in Section E below; (9) Periodic testing or providing member’s proof of exemption to the Coast Guard; (10) Medical Review Officer (MRO) services including verification of test results, chain of custody verification, direct interview of employee/contractor in case of positive tests, and second medical confirmation of positive tests; (11) Recordkeeping of all positive test results for five years, and negative results for one year; (12) Management Information Systems (MIS) reporting to the Coast Guard and a Certificate of a MIS Filing during membership term; (13) Coast Guard notification of failures to test, termination, or positive test results as required by regulation and/or law.

B. Program Documentation
Maritime will provide Member Company: (1) Identification cards for all enrolled Captains and crew. Such cards will be used as proof of the employee’s enrollment in random drug testing, and will contain a unique computer generated ID number; (2) A letter confirming Member Company’s compliance for use during Coast Guard Audit; (3) Drug-Free Vessel sticker; (4) Access to a password-protected website containing a company drug testing policy, copies of Coast Guard regulations, testing procedures, Employee Assistance Program materials (includes contact information for Substance Abuse Professionals), and employee statement of understanding. Upon request, Maritime will also provide the following at no charge to the member: (1) Replacement ID card; (2) Replacement Certificate of Enrollment; (3) Coast Guard approved letter for license renewal; (4) Coast Guard Audit Package including the USCG Audit form and full listing of prior drug tests performed by Maritime.

C. Guarantee of Compliance
Maritime provides a guarantee that the Maritime’s services to the Member Company are in compliance with DOT/Coast Guard drug testing regulations, as contained in 46 CFR parts 4, 5, 16, and 49 CFR part 40. It is understood that should these DOT/Coast Guard drug-testing regulations be changed or modified, Maritime retains the right to adjust fees to take into account any additional costs required by any new regulation.

D. Company Responsibilities
(1) Per Coast Guard regulations, Member Company is responsible for complying with Coast Guard pre-employment testing regulations, as described in section E below; (2) To appoint a Designated Employer Representative (DER) who will be the contact person for test notices, tests results as well as all company correspondence. Notify Maritime in writing when/if DER information changes; (3) To ensure that current mailing address, phone and fax numbers and email address are provided to Maritime and that should secondary (or off-season) contact information be available, that it too be provided to Maritime; (4) Company responsibilities include promptly enrolling new employees; and (5) properly following random testing instructions including taking any test immediately. The Member Company shall indemnify, hold harmless, and defend Maritime against legal actions arising out of or in connection with Company’s failure to comply with federal law or policy due to any breach of this agreement.

E. Coast Guard Pre-Employment Test Regulations
As required by 46 CFR part 16, when hiring a new employee or enrolling in a random program for the first time, members must submit to a pre-employment test prior to enrollment in any random testing program. Once a test is performed and an acceptable result is received, all enrollment benefits (see Sections A and B) apply to the new employee for the membership term. Any person joining a drug-testing program must be pre-employment tested upon enrollment to verify drug-free status. Maritime offers this pre-employment test is available for an additional $55 per test. A person shall be deemed exempt from the pre-employment test if he/she has had a NIDA 5 Chemical Drug Test within 6 months prior to enrollment, or has been subject to random testing for 60 consecutive days within the past 6 months, as per 46 CFR part 16. Maritime can only verify full compliance by having a copy of pre-employment documentation on file for each employee.


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The Maritime Consoritum, Inc. • PO BOX 4070 • Annapolis, MD 21403-6070 •

Tel: (800) 775-6985 Fax: 410-263-3186 • email info@drugfreevessel.com

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