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COMPANY / TERMINAL & DER
DRUG PROGRAM
REGISTRATION FORM AND
AGREEMENT
This Agreement is
entered into between NTA Inc. and the Company below for the purpose of
establishing NTA Inc. as the Company’s Sole Substance Abuse Program
Administrator for a minimum period of one year from the date of acceptance
of enrollment by NTA Inc. The company may renew its enrollment for
successive renewal terms of one (1) year upon payment of NTA’s then
prevailing renewal fee. By submitting this form, you agree to accept our
billing system accounting for all purchases on this account.
Execution of this
registration form constitutes that the Company & DER agrees to comply and
follow all substance abuse regulations as mandated by the applicable state
and federal regulations and, if it fails or refuses to comply with such
regulations, it will indemnify and hold harmless NTA Inc., it’s officer’s,
agents, independent contractors, laboratories, collection sites and
Medical Review Officer’s providing services to the Company under this
agreement from and against any liability, cost or expense resulting from
such failure or refusal. If the Company and/or DER submits a sample for
testing from persons not subject to mandatory testing under said
regulations, the Company & DER warrants and agrees to comply with all
applicable federal and state laws. The Company is advised to consult its
legal counsel prior to putting any policy in place or taking any action
against any employee as a result of actions related to the regulations.
The Company guarantees
to forward all fees due as described in Programs I & II within
ten (10) days of date of invoice. THIS FORM MUST BE SIGNED by
an authorized representative of the Company and returned with the
applicable amount to NTA Inc. before the program can be started. Please
keep a copy of this form as proof of Company agreement with NTA Inc. You
can expedite their enrollment by returning this application to:
NTA Inc.
California Information
Center
For
Office Use Only
2525 Signal Hill, CA
90755
NTA
ID # _______________
PLEASE PRINT
Date:_______________________
Name of Company:
__________________________________________________________________________________________
Mailing Address:
____________________________________________________________________________________________
Physical Address:
____________________________________________________________________________________________
City/State:
_____________________________________________________ Zip code:
_______________________________
Phone: ( )
_______________________________________ FAX: ( )
__________________________________
Total number of drivers to be enrolled: __________
US DOT____________________ FMSCA
MC______________________ STATE AUTHORITY # ____________________
DESIGNATED EMPLOYER
REPRESENTIVE (DER) WHO WILL BE RESPONSIBLE OF DRUG AND ALCOHOL TESTING
The person or persons you designate will be your
DER, authorized to receive test results and other confidential
information. It is important to have an alternative in the event your
primary company confidant cannot be reached. The undersigned further
personally guarantee that all regulations will be adhered to and to the
payment of all invoices.
Name: ____________________________________________
Alternate’s Name:___________________________________
Title: ______________________________________________
Title:______________________________________________
Office Phone: ( )
___________________________________ Office Phone: ( )
__________________________________
PREFERRED METHOD OF
RECEIVING DRUG TEST RESULTS
Secured Fax ( )
_______________________________
Phone ( )
_______________________________
eMail
__________________________________________________ |
