Consortium Enrollment Form

Client Details:

Business Name*

NameEIN

Full Name*

First NameLast Name

Business Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

E-mail

example@example.com

Owner Operator?*

Number of Employees*

CDL # and State*

DOT Number

Name, DOB, CDL # and State for each employee (if Applicable):

My Products

ConsortiumDOT Random Drug & Alcohol testing pool

$275.00 Quantity

Total

$0.00

Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

CONSORTIUM AGREEMENT
Clear Path Screenings – DOT Compliance Package

Effective Date: Is the date the application is submitted

This Agreement (“Agreement”) is entered into between Clear Path Screenings (“Service Provider”) and company listed on form (“Client”) for the provision of drug and alcohol testing services as required by the U.S. Department of Transportation (DOT) to ensure compliance with federal regulations.

1. Services Provided:
Clear Path Screenings will provide the following services under this Agreement:

Pre-Employment Drug & Alcohol Testing: All prospective employees will undergo drug and alcohol testing as part of the pre-employment process.
Random Drug & Alcohol Testing: Ongoing random drug and alcohol testing for employees subject to DOT regulations.
Clearinghouse Reporting: Uploading of testing data to the FMCSA Clearinghouse as required for all regulated drivers.

2. Term:
This Agreement will remain in effect for one (1) year from the Effective Date. Either party may terminate this Agreement with thirty (30) days' written notice. Upon termination, the Client will remain responsible for any outstanding payments due for services rendered before the termination date.

3. Client Responsibilities:

Provide the necessary information for pre-employment testing and ongoing random selection.
Ensure all designated employees comply with DOT testing regulations.
Timely payment of fees for the services provided under this Agreement.

4. Fees & Payment Terms:
Services will be billed in accordance with the pricing schedule provided. Payment is due at the time of application.

5. Confidentiality:
Both parties agree to maintain the confidentiality of test results and other sensitive information in compliance with applicable privacy laws.

6. Liability:
Clear Path Screenings will not be held liable for any delays or failures in testing or reporting due to events outside its control, such as delays in lab results or regulatory changes.

By signing below, both parties agree to the terms outlined in this Agreement.

For Clear Path Screenings:

Majorya Pascal

Lab Director and:

For company listed on this form:

Please sign & date below.

This brief agreement covers all required testing services and ensures compliance with DOT regulations for a period of one year.

Signature

Date