Sign Me Up ! - Drug Free Business

Sign Me Up

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Company

This field is for validation purposes and should be left unchanged.

Please enter your information and then click on the "Submit" button. Drug Free Business Client Services will contact you to set up convenient collection sites and obtain additional information if needed. Please don't hesitate to call Drug Free Business if you have any questions about getting started. 425-488-9755 or 866-448-0651. Fields with a red asterisk * are required.

Is your company seeking services only for its own employees, or does it also plan to act as a service provider for external companies?*

Exclusively for our own employees

Acting as a service provider for external companies (Requires Master Service Agreement; additional details will be requested)

Acting as a service provider for external companies will require a Master Service Agreement and additional details will be requested. Our Client Services group will contact you and assist you with set up and adding new companies. Please check your email after submitting this online form.

Testing Programs Needed*

Please select the types of testing programs you want us to set up for you.

Dept. of Transportation (DOT) testing only

Non-DOT employee testing only

Both DOT covered employees and Non-DOT employees

None at this time – I want to sign up for background screening only.

Are any of your Non-DOT workers employed in WA State or California?

Yes

After submitting this form, we will contact you to determine your best testing options to be compliant with new laws in those states.

Section - Contact Info

Name of Company*

Contact Person

First Last

Your Accounts Payable Email Address IF Different

Phone

Work Address*

Physical Address - testing forms can't be sent to PO Box. Address Line 2 or P.O. Box City State ZIP Code

Section - DOT Program Application

DOT Program Application*

Choose which program or DOT agency - If covered by multiple modes please explain in remarks,

FMCSA (Motor Carrier)

FAA (Aviation)

US Coast Guard

FTA (Transit)

PHMSA (Pipeline)

FRA (Railroad)

FAA Certificate ID*

FAA Certificate - 8 characters alpha-numeric certificate number

Upload a copy of your FAA Certificate*

Accepted file types: jpg, gif, png, pdf, jpeg, Max. file size: 256 MB.

FAA now requires service agents to obtain a copy of your FAA Certificate.

“Employees not covered by FAA regulations 14 CFR Part 120 may not be part of the same random pool with FAA-covered safety-sensitive employees. 49 CFR § 40.347(b)(2).*

I acknowledge this requirement

Number of drivers in your FMCSA Program?*

Owner/Operator: An owner-operator is any employer who employs himself or herself as a CDL driver. Owner-operators are subject to the requirements pertaining to employers as well as those pertaining to drivers. FMCSA Clearinghouse services are included.

1-7 drivers - small business consortium

8+ drivers - your own random pool

Number of DOT covered employees in program

Quarterly or Monthly Random Selections

Quarterly

Monthly

If you have a large number of employees in your pool you may choose monthly random selections

Start date for your random selections

Our system makes random selections on first working day of the quarter or month

USDOT Number

If not sure, enter "Unknown"

Should match the name associated with your USDOT number.

You can determine your USDOT Number(s) by going to https://safer.fmcsa.dot.gov/CompanySnapshot.aspx and search by "name".

Section - DER info

Name(s) of Designated Employer Representative (DER) to receive confidential random notices and confidential test results.

Name of Designated Employer Representative (DER)*

First Last

Name of Designated Employer Representative (DER) to receive confidential random notices and test results. It can NOT be the driver.

Name of Designated Employer Representative (DER)*

First Last

Email for Designated Employer Representative (DER)*

Phone of Designated Employer Representative (DER)*

Fax - will be printed on testing forms so collectors can send you copies

Name of Secondary Designated Employer Representative (DER)

First Last

Name of Secondary Designated Employer Representative (DER) to receive confidential random notices and test results. Not required but highly recommended.

Phone of Secondary Designated Employer Representative (DER)

Email for Secondary Designated Employer Representative (DER)

Section - Non-DOT Testing Program Info

Total number of employees in your non-DOT testing program*

Estimate - may vary.

Optional - We provide random selection service at no extra charge. Do you want random selections for your non-DOT programs?

Yes

I'm not sure - tell me more

We will contact you to get an employee roster for random selections, the percentage you want to be tested (50% per year is typical), quarterly or monthly, and other details.

We will contact you to explain the various options available to you at no extra charge and the reasons why employers implement random testing programs.

Quarterly or Monthly Random Selections for your non-DOT pool

Quarterly

Monthly

If you have a large number of employees in your pool you may choose monthly random selections

Section - Additional Info

Please contact me with information about:

Tell me more about DFB's low-cost employee background screening

Tell me more about Employee Assistance Program (EAP) coverage

Tell me more about using electronic custody & control forms

Please add any other information you think we need to know to facilitate setting up your account.

Please tell us who referred you to DFB? If you are coming from another 3rd party administrator this will help with continuity if we need to obtain additional information.

Drug Free Business FMCSA-Owner-Operator Consortium Pool Requirements: Upon receipt of this application, and credit card payment of the annual membership fee of $200 and a $50 fee for Drug Free Business to provide the required Clearinghouse services for owner-operators, we will initiate the setup of your account and services. Mandatory use of the FMCSA Drug & Alcohol Clearinghouse begins January 6th, 2020. As an owner-operator, you are required to employ the services of a Consortium/Third-Party Administrator (CTPA). We charge a $50.00 Clearinghouse fee per year to cover these employer reporting requirements. You must also be registered as a Driver at the Clearinghouse, and have selected Drug Free Business as your C/TPA (3rd Party Administrator) before the account setup can be completed. We may contact you to obtain additional information, e.g. collection site preferences, etc. All new members will receive a Drug Free Business welcome email, which includes a sample policy and additional materials to help you create your drug-free workplace and/or stay in compliance with DOT testing regulations. Once selected for a random drug and or alcohol test, you must report to a collection/testing site immediately upon receipt of the selection notice. This is the only notice you will receive. Failure to report for testing could result in a ‘refusal to test’ which may directly affect your CDL and could cause you to be removed from the testing pool and forfeit any fees paid. It is your responsibility as a member of the pool to notify Drug Free Business immediately of any changes in your driving status, contact information or changes in phone or address for your company. You must notify all current employers and Drug Free Business in writing of any violation of the alcohol and drug prohibitions under 49 USC Part 40 before the end of the business day following the day you received notice of the violation (§382.415). If you violate any of the DOT or FMCSA drug and alcohol regulations, including failing or refusing a required drug or alcohol test, Drug Free Business is required to report the violation to the FMCSA Clearinghouse. For the integrity of the consortium pool, you must agree to adhere to these rules, failure to do so will cause you to be removed from the pool and your membership canceled. By completing this application, you hereby acknowledge responsibility for all Consortium rules, payment in full of annual membership dues, and/or any testing services rendered. You must keep DFB informed of any changes to phone number, address, and/or driving status (DOT Rule 49 CFR Part 40 Section 40.11 Employer Responsibilities). You must be available for testing as required. The inability to contact you by e-mail or phone will result in automatic removal and termination from the pool. Cancellation of services or membership requires 30 days prior written notice. Fees are nonrefundable after setup completed. Payment is due within 15 days of the invoice date. Accounts over 45 days past due may be subject to a 1.5% monthly interest charge (18% APR) and a late fee of $10 or more on balances exceeding $100. To avoid service interruptions and finance charges, please ensure timely payment. We appreciate your prompt attention!*

I AGREE TO ALL MEMBERSHIP RULES AND REQUIREMENTS

Drug Free Business Small Business Consortium Pool Requirements: Upon receipt of this application, payment of the annual membership fee of $150 will be billed and must be paid before the account setup can be completed. All new members will receive a Drug Free Business welcome email, which includes a sample policy and additional materials to help you create your drug-free workplace and/or stay in compliance with DOT testing regulations. It is your responsibility as a member of the pool to notify Drug Free Business immediately of any changes in your status, contact information or changes in phone or address for your company. For the integrity of the consortium pool, you must agree to adhere to these consortium rules, DOT 49CFR40 regulations, and your DOT Operating Administration regulations. Failure to do so will cause you to be removed from the pool and your membership canceled. By completing this application, you hereby acknowledge responsibility for all Consortium rules, payment in full of annual membership dues, and/or any testing services rendered. You must keep DFB informed of any changes to phone number, address, and/or driving status (DOT Rule 49 CFR Part 40 Section 40.11 Employer Responsibilities). Your covered employees must be available for testing as required. The inability to contact you by e-mail or phone will result in automatic removal and termination from the pool. Cancellation of services or membership requires 30 days prior written notice. Fees are nonrefundable after setup is completed. Payment is due within 15 days of the invoice date. Accounts over 45 days past due may be subject to a 1.5% monthly interest charge (18% APR) and a late fee of $10 or more on balances exceeding $100. To avoid service interruptions and finance charges, please ensure timely payment. We appreciate your prompt attention!*

I AGREE TO ALL MEMBERSHIP RULES AND REQUIREMENTS

Drug Free Business Member Application: Upon receipt of this application, Drug Free Business will invoice your company for the $150 annual membership fee. Drug Free Business will contact you to setup your program and provide assistance and consultation including policy and procedure templates. All new members will receive the Drug Free Business membership packet, which includes sample policies and additional materials to help you create your drug-free workplace and/or stay in compliance with DOT testing regulations. I acknowledge my employer responsibilities as defined in DOT Rule 49 CFR Part 40 Section 40.11 Employer Responsibilities. By completing this application, your company hereby acknowledges responsibility for payment in full of annual membership dues, and/or any services rendered. Cancellation of services or membership requires 30 days prior written notice. Fees are nonrefundable after setup completed. Payment is due within 15 days of the invoice date. Accounts over 45 days past due may be subject to a 1.5% monthly interest charge (18% APR) and a late fee of $10 or more on balances exceeding $100. To avoid service interruptions and finance charges, please ensure timely payment. We appreciate your prompt attention!*

I AGREE TO ALL MEMBERSHIP RULES AND REQUIREMENTS

Total for Membership Fees

Payment Method

American Express

Discover

MasterCard

Visa

Supported Credit Cards: American Express, Discover, MasterCard, Visa

Card Number Expiration Date Security Code Cardholder Name