Please fill out the form below to become a participant in the program. If you would like to read more details about the plan or prefer to view, print and mail us this form via the post office click here for a PDF version of the form. All Fields marked with * are required to submit the form.
General Information:
Company Name:*
Address:*
City:*
State:*
None 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 Washington D.C. West Virginia Wisconsin Wyoming
Zip:*
Phone:*
Email:*
Designated Employer Representative(s):*
Representative #1:
Representative #2:
Collection Site:
Lakewood Clinic 5203 Lakewood Blvd. Lakewood, CA. 90712
Commerce Clinic 6538 Telegraph Road Commerce, CA. 90040
La Mirada Clinic 15330 Valley View Ave. La Mirada, CA. 90638
Services:
Enrollment:
1. An annual enrollment of $100 and $30 per person per year. *This choice includes all random drug and alcohol tests at no additional charge. If client is selected for testing through out the year, the tests are FREE.
All non-random Federal tests will be $50. All non-random breath alcohol tests will be $15. For more pricing options and packages, call now! (714) 443-0330
Persons Enrolled: *
Participant Information:
Please submit your company's participant information. All employees that are in safety sensitive positions should populate this list. To submit the information you may either:
1. Email an excel file to administrator@consortiumcompliance.com 2. Fax a current list to (714) 443-0299. Please make fax attention to Donna.
Supervisor Training:
Call for class schedule and pricing.
DER Training:
E-Compliance Membership:
$9/month Sign up for a year and get a month FREE!
Billing Details:
Payment Type:
Invoice (All invoices are due within 30 Days)
Credit Card (By selecting this option we request that you fill in the card details below. We will send an email confirmation with your final total before any charges are actually applied to your card.)
Name On Card:
Card Type:
Select Card Type Visa Mastercard Discover American Express
Card Number:
Expiration:
Month (xx) Year (xxxx)
CSV:
(Three Digit Code On Back Of Card. For American Express It Is Four Digit Code Above Account Number To The Right)
Billing Street:
Billing City:
Billing State:
Billing Zip:
Consortium Member Agreeement:
* You acknowledge that there is an agreement between Consortium Compliance and you (the employer). The following details are covered under this agreement.
1. Consortium Compliance offers the Random Drug Testing Program as a service to its members, but sole responsibility of compliance with the Department of Transportation Regulations remains with Employer. 2. Consortium Compliance will perform: Random Selection, Facilitation of Collection Site, Laboratory Analysis, Medical Review Officer (MRO) services, Management Information Systems (MIS) reports, and Bi-annual drug testing summary reports. 3. Consortium Compliance agrees to maintain current documentation pertaining to pre-employment test results, participation lists, and drug and alcohol notification records for all active participants. All other required record keeping is the responsibility of the Employer. 4. The Employer is responsible for: revisions of participant lists, participant notification of Random Drug and Alcohol testing, selection of the Designated Employer Representative (DER) and all applicable provisions of Part 40 and DOT agency drug and alcohol testing regulations. 5. Employer understands that it is Consortium Compliance's policy to report non-compliance to the appropriate agency. 6. Employer agrees to pay Consortium Compliance the fees set out in the fee schedule. This includes payment for enrollment, drug and alcohol testing fees per driver, pre-employment examination, post accident testing, follow-up/return to duty testing, reasonable suspicion testing, expedited enrollment fees, manager and supervisor training and website fees. 7. Employer will provide Consortium Compliance complete contact information, including name, social security number, and hire date of each safety sensitive employee. 8. For all records and services the employer requires on the same business day requested, Consortium Compliance reserves the right to charge an expedited handling fee that is due at time of service. Normal turn around on all services is two (2) business days. 9. This agreement shall remain in effect until terminated by one of the parties and is only in effect for one (1) year from date of signing. This agreement may be cancelled via written notice by either party at any time.
