Thank you for your interest in joining our Random Drug Testing Program. After completing this form a starter package will be sent to you within two business days along with either an invoice or credit card confirmation.
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.
NoneAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWashington D.C.West VirginiaWisconsinWyoming
Designated Employer Representative(s):*
5203 Lakewood Blvd.
Lakewood, CA. 90712
6538 Telegraph Road
Commerce, CA. 90040
La Mirada Clinic
15330 Valley View Ave.
La Mirada, CA. 90638
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: *
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 firstname.lastname@example.org
2. Fax a current list to (714) 443-0299. Please make fax attention to Donna.
Call for class schedule and pricing.
$9/month Sign up for a year and get a month FREE!
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:
Select Card TypeVisaMastercardDiscoverAmerican Express
Month (xx) Year (xxxx)
(Three Digit Code On Back Of Card. For American Express It Is Four Digit Code Above Account Number To The Right)
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.