Sign Me Up"*" indicates required fieldsPlease 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 800-598-3437. Fields with a red asterisk * are required.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 take advantage of other DFB membership benefitsSection - Contact InfoName of Company*Contact Person First Last Email Your Accounts Payable Email Address IF Different PhoneWork Address* Physical Address - testing forms can't be sent to PO Box. Address Line 2 or P.O. Box City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Section - DOT Program ApplicationDOT 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 IDFAA Certificate - 8 characters alpha-numeric certificate numberNumber 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 poolNumber of DOT covered employees in programQuarterly or Monthly Random Selections Quarterly MonthlyIf you have a large number of employees in your pool you may choose monthly random selectionsStart date for your random selections MM slash DD slash YYYY Our system makes random selections on first working day of the quarter or monthUSDOT NumberIf 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 infoName(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 copiesName 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.Email for Secondary Designated Employer Representative (DER) Phone of Secondary Designated Employer Representative (DER)Section - Non-DOT Testing Program InfoTotal 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 No I'm not sure - tell me moreWe 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 MonthlyIf you have a large number of employees in your pool you may choose monthly random selectionsSection - Additional InfoPlease contact me with information about: Tell me more about DFB's low-cost employee background screening Tell me more about Employee Assistance Program (EAP) coveragePlease 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 before 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. I AGREE TO ALL MEMBERSHIP RULES AND REQUIREMENTSDrug 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. I AGREE TO ALL MEMBERSHIP RULES AND REQUIREMENTSDrug 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. I AGREE TO ALL MEMBERSHIP RULES AND REQUIREMENTSTotal for Membership Fees Payment MethodCredit CardAmerican ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Expiration Date Security Code Cardholder Name NameThis field is for validation purposes and should be left unchanged.