Company Enrollment Application Classification DOT (26,000 + Lbs) CA# Charter/Passenger Towing FTA Other Company Name Principal Owner(s) Mailing Address Phone Primary Contact Phone & Email Alternate Contact Phone & Email Within the last 6 months has your company been enrolled in a Substance Abuse Program? Yes No If YES please provide name Complete Program Fees Owner/Op: $150 2 thru 5: $109 Each 6 thru 10: $99 Each 11 thru 20: $89 Each 21 or More: Special Pricing For 20 or more, continue on with your submission. We will contact with special pricing. 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 anytime 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. Agree to Participate I agree Authorized Representative Date Result Reporting & Employee / Driver Profile The information provided in this section will establish the protocol that ADTS will follow when reporting the confidential test results to your company. Changes to this protocol must be made in writing. Confidential drug testing information to be reported to: Primary Name Primary Email Alternate Name Alternate Email As an authorized Representative of the above named company and by selecting "I agree", I acknowledge that the above protocol be established for my company when receiving confidential drug test results and further more that any changes to future protocol will be in the form of a written request. Agree to Reporting I agree We will accept your company employee list in lieu of our Employee / Driver Profile _________________________________________ Name DL# & State of Issue License Class A B C _________________________________________ Name DL# & State of Issue License Class A B C _________________________________________ Name DL# & State of Issue License Class A B C _________________________________________ Name DL# & State of Issue License Class A B C _________________________________________ Name DL# & State of Issue License Class A B C _________________________________________ Name DL# & State of Issue License Class A B C _________________________________________ 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 Send