M2Z COMPLIANCE SOLUTIONS
FMCSA Return-to-Duty (RTD) Program - Driver & Owner-Operator Intake Form
Phone:
1-888-282-2279
Email:
info@m2zcompliance.com
Website:
www.m2zcompliance.com
This form is for CDL drivers and owner-operators completing the FMCSA Return-to-Duty (RTD) process under 49 CFR Part 40. M2Z Compliance Solutions may act as your Consortium/Third-Party Administrator (C/TPA) to coordinate drug testing and compliance documentation.
SECTION A: DRIVER INFORMATION
Full Legal Name
First Name
Last Name
Date of Birth (MM/DD/YYYY)
-
Month
-
Day
Year
Date
Social Security Number (Last 4 Digits - Optional)
CDL Number/Driver License Number
State of Issue
License Expiration Date
-
Month
-
Day
Year
Date
Mobile Phone Number
Format: (000) 000-0000.
Email Address
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
SECTION B: DRIVER TYPE & ROUTING
Are you an Owner-Operator? (Yes / No)
Yes
No
Do you have an active FMCSA DOT Number? (Yes /No)
Yes
No
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Next
If Yes, enter your DOT Number
What best describes your situation?
If Other, please explain
SECTION C: CLEARINGHOUSE INFORMATION
Clearinghouse Login Email
example@example.com
Clearinghouse Driver ID (Optional)
SAP Case Number
Violation Type
Date of Violation
SECTION D: SUBSTANCE ABUSE PROFESSIONAL (SAP) INFORMATION
SAP Name
SAP Phone Number
Format: (000) 000-0000.
SAP Email
example@example.com
SAP Website
Has your SAP declared you eligible for Return-to-Duty testing? (Yes / No / Not sure)
Yes
No
Not Sure
SECTION E: EMPLOYER INFORMATION (IF APPLICABLE)
Are you currently employed as a CDL driver? (Yes / No)
Yes
No
Current Employer Name
Employer DOT Number
Employer Contact Name
Employer Contact Phone
Format: (000) 000-0000.
Employer Contact Email
example@example.com
Recruiter or Company Name (if applicable)
Back
Next
SECTION F: STEP 6 & CONSORTIUM PREFERENCES
Would you be interested in having M2Z Compliance Solutions manage your Step 6 follow‑up testing plan? (Yes / No)
Yes
No
If you have an active DOT Number, would you be interested in enrolling in our DOT consortium program? (Yes / No)
Yes
No
SECTION G: OBSERVED DRUG TEST ACKNOWLEDGMENT
I understand that all DOT Return-to-Duty drug tests must be directly observed in accordance with 49 CFR §40.67.
YES, I understand and acknowledge the observed test requirement
SECTION H: CONSENT TO ACT AS CONSORTIUM / THIRD-PARTY ADMINISTRATOR (C/TPA)
I authorize M2Z Compliance Solutions to act as my Consortium/Third-Party Administrator for coordination of my Return-to-Duty process.
I authorize M2Z Compliance Solutions to act as my C/TPA
SECTION I: PAYMENT AGREEMENT
I acknowledge responsibility for all RTD program fees.
SECTION J: REFUND & CHARGEBACK POLICY
I have read and understand the refund and chargeback policy.
SECTION K: ELECTRONIC SIGNATURE
Typed Name (Electronic Signature)
Date
-
Month
-
Day
Year
Date
Submit RTD Driver Intake Form
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