M2Z Compliance Solutions
FMCSA Return-to-Duty (RTD) Program - Driver Intake & Consent Form
Phone:
1-888-282-2279
Email:
info@m2zcompliance.com
Website:
www.m2zcompliance.com
This form is used for drivers completing the FMCSA Retum-to-Duty (RTD) process in accordance with 49 CFR Part 40. M2Z Compliance Solutions may act as your Consortium/Third Party Administrator (C/TPA) to coordinate drug testing and compliance documentation.
Driver Information
Full Legal Name
Date of Birth
-
Month
-
Day
Year
Date
Social Security Number
CDL Number
Driver License Number
State of Issue
Expiration Date
-
Month
-
Day
Year
Date
Phone Number
Format: (000) 000-0000.
Email Address
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Clearinghouse Information
Clearinghouse Login Email
example@example.com
Clearinghouse Driver ID
Back
Next
SAP Case Number
Violation Type
Positive
Refusal
Actual Knowledge
Substance Abuse Professional (SAP) Information
SAP Name
SAP Phone
Format: (000) 000-0000.
SAP Email
example@example.com
SAP Website
Upload SAP Completion Letter
Attach copy when submitting form
Employer Information (If Applicable)
Employer Name
Employer DOT Number
Employer Contact Name
Employer Phone
Format: (000) 000-0000.
Employer Email
example@example.com
Back
Next
Observed Drug Test Acknowledgment
I understand that all Retum-to-Duty drug tests must be directly observed in accordance with 49 CFR §40.67. Observed means a collector of the same gender watches the urine leave the body and enter the collection cup.
YES, I understand
Consent to Act as Consortium / Third Party Administrator (C/TPA)
By signing this document, I certify that the information provided is true and correct. I authorize M2Z Compliance Solutions to act as my Consortium/Third Party Administrator in the FMCSA Drug & Alcohol Clearinghouse. M2Z Compliance Solutions may coordinate drug testing, perform Clearinghouse queries, maintain compliance documentation, and communicate with laboratories and Substance Abuse Professionals regarding my Return-to-Duty process.
Payment Agreement
I acknowledge that I am responsible for all fees associated with the Return-to-Duty program and authorize M2Z Compliance Solutions to begin services upon submission of this form.
I agree to the payment terms
Refund & Chargeback Policy
All sales are final. Services are non-refundable and non-transferable. M2Z Compliance Solutions maintains documentation including signed agreements, drug testing records, communications, and payment confirmations which may be used to respond to disputes or financial chargebacks.
Electronic Signature Authorization
Driver Signature
Date
-
Month
-
Day
Year
Date
Preview PDF
Submit
Should be Empty: