DRUG CONSORTIUM APPLICATION 2010
You must be a member of a maritime organization (LECBA, West Sister, etc). Send a copy of your current random drug testing card with your application. If you do not have one you will have to pre-employ at your expence. Call (419) 734-2670 if you need an application.CAPTAIN___________ MATE_________
NAME_______________________________________
ADDRESS ___________________________________
CITY_________________________________________
STATE__________________ ZIP______________
EMAIL_______________________________________
HOME PHONE NUMBER_______________________
CELL PHONE NUMBER_________________________
DATE OF BIRTH________________________
SOCIAL SECURITY NUMBER__________________
USCG LICENSE # ____________________________
EXPIRATION DATE_____________
Are you currently a member of a maritime drug consortium?
Yes ______ No________
OH or Documentation #’s________________________
SIGN ________________________________________
DATE ________________
$ 45. DUES ARE EFFECTIVE
JANUARY 1 to DECEMBER 31 of current year
Make checks payable to LECBA Drug Program
mail to:
LECBA Drug Program
c/o Sandee Abele
245 N Worthy
Lakeside, OH 43440
Questions call Sandee Abele
(419) 732-2670
email: saja@cros.net