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 *

### - ### - ####

Your Cell Phone number; *

### - ### - ####

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 *

### - ### - ####

Enter best contact phone for backup DER

### - ### - ####

Drug Free Business DOT Consortium Pool Requirements

Upon receipt of this application, payment of the annual membership fee of $200 will be billed and must be paid before the account setup can be completed. Additionally, 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 $15.00 Clearinghouse fee per year to cover our Clearinghouse services to you. You must also be registered for the Clearinghouse before 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. Once selected for a random drug and or alcohol test, you must report 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 of 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 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 REQUIREMENTS

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

Optional: Enter Your Message