EmailMe Form - DOT Consortium Membership Application

Name of Company *

Main Contact Name *

First Last

Secondary Contact (required if main contact is driver)

First Last

Your Work Email *

Your Work Phone *

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Your Cell Phone number; *

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Work Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Total Number of Employees subject to DOT testing requirements *

Which DOT Operating Administration (check one) *

Random Selection Rosters:

You can send your employee list(s) with CDL# and state of issuance to randomselections@drugfreebusiness.org or fax your list(s) to 425-488-0832. Note that after 1/1/2018, FMCSA requires you to use CDL number and state of issuance for driver's ID.

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

Name of Backup DER - recommended:

Enter email address of primary DER *

Enter email address of backup DER

Enter best contact phone for primary DER *

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Enter best contact phone for backup DER

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Drug Free Business DOT Consortium Pool Requirements

Upon receipt of this application, payment of annual membership fee of $200 and the cost of your pre-employment test needed to enter the random pool your Federal Custody & Control Form will be billed and paid before setup. All new members will receive the Drug Free Business membership packet, 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.

DOT mandates random selection services for commercial drivers (CDLs), our consortium pool is selected quarterly at the DOT required minimum 25% Drugs and 10% Alcohol of the yearly average of total members in that pool. Per the DOT regulations each driver has an equal chance of being selected during each selection period.

If selected, you will receive a selection notice with custody and control form and directions to the nearest collection facility. You must report immediately upon receipt of this selection notice. This is the only notice you will receive. Failure to report for testing could result in a ‘refusal to test’ which could directly affect your CDL and your removal from the testing pool.

It is your responsibility as a member of the pool to notify DFB immediately of any changes in your driving status, or changes in phone or address or any contact information. 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 cancel your membership.

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 or address and/or driving status. (DOT Rule 49 CFR Part 40 Section 40.11 Employer Responsibilities) You must be available for testing as required. Inability to contact you by e-mail or phone will result in automatic removal and termination from the pool. *

I AGREE TO ALL MEMBERSHIP RULES AND REQUIREMENTS

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

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