Date:

Name of Company:

Address:

Main Contact or DER (person to receive drug test results)

Name:

Email:

Phone:

Fax:

DOT Regulatory authority: choose one:
FMCSAFAAFRAFTAPHMSAUSCG

Are you currently enrolled in a consortium? YesNo

If yes, name of consortium:

If no you must provide proof of a negative drug screen in the last 30 days or take a pre-employment drug screen.

Please provide list of drivers on spread sheet or separate document.