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Company Enrollment
Application
CLASSIFICATION:
FMCSA
FAA
FRA
FTA
PHMSA
USCG
PUC
TOW
Other
Company Name:
(Required)
Principal Owner(s):
(Required)
Physical Address:
(Required)
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Mailing Address:
The mailing address is the same as above
Mailing Address:
(Required)
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Primary Account Contact:
(Required)
Phone
Email
Alternate Account Contact: (If applicable)
Phone
Email
Within the last 6 months has your company been enrolled in a Substance Abuse Program (consortium)?
(Required)
Yes
No
If YES Please provide name:
PROGRAM ENROLLMENT & FEES
(Required)
1 Participant (Owner/Op): $150 / 2 thru 5 Participants: $109 Each / 6 thru 10 Participants: $99 Each / 11 thru 20 Participants: $89 Each / 21 or More Participants: Special Pricing / Other Program: Special Pricing
Price:
# of Participants
(Required)
Other Program: Special pricing – please contact us for custom quote.
21 or more participants: Special pricing — please contact us for a custom quote.
Total
We will contact you soon to arrange payment and confirm completion of your enrollment application.
New eligible employees must be queried though the Clearinghouse, pre-employment tested and added to your random pool PRIOR to performing safety sensitive duties.
Company Participant List
We will submit participant list by email in lieu of our Participant / Driver Profile
Participant 1 Name:
Driver License #
State of Issue
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Class
A
B
C
Participant 2 Name:
Driver License #
State of Issue
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Class
A
B
C
Participant 3 Name:
Driver License #
State of Issue
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Class
A
B
C
Participant 4 Name:
Driver License #
State of Issue
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Class
A
B
C
Participant 5 Name:
Driver License #
State of Issue
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Class
A
B
C
Consent
(Required)
Agree to Participate
As an Authorized Representative of the above-named company, I hereby agree to participate in the ADTS~Alcohol & Drug Testing Services Substance Abuse Program as indicated. I agree to abide by all rules, policies and procedures of the program. I acknowledge that at any time either party may cancel this contract with a thirty- (30) day written notice. I acknowledge enrollment in this program will expire 12 months from the date of this contract and that this contract will automatically renew on the next day following expiration unless notification in writing is received by ADTS prior to the expiration date. I understand the entire contents of the ADTS~Alcohol & Drug Testing Services Substance Abuse Program is the sole property of ADTS and cannot be transferred or reproduced in any fashion without the express written permission of ADTS~Alcohol & Drug Testing Services.
Authorized Representative:
(Required)
Title:
(Required)
Date
(Required)
MM slash DD slash YYYY
Services Included in Program
Quarterly Compliance Package
Certificate of Compliance
24-Hour Support Service
Random Selection Program for Drug & Alcohol Testing
MIS Reporting & Record Maintenance
Random Urine Drug Screen, Collection, Analysis, MRO
GCMS Confirmation, if required
Random Alcohol Testing (With Confirmation)
Nationwide Testing Locations
Additional Services Provided @ Fee Schedule
Pre-Employment Testing
Post-Accident Testing
Suspicion & Cause Testing
Return-to-Duty & Follow Up testing
Reanalysis or Split Specimen Testing
Hair Testing
Rapid Drug Screen Testing
Alcohol Testing
On-Site Testing