C/TPA Enrollment Form

C/TPA Enrollment Form

Complete this form to enroll in our compliance services
Company Information
Legal Business Name
DOT Number
MC Number
EIN
Business Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Mailing Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Company Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Company Email Address
example@example.com
Website
Type of Business
Number of CDL Drivers
Number of Non-CDL Employees
States Company Operates In

Other
Primary Contact Information
Primary Contact Name

First NameMiddle NameLast Name
Job Title
Direct Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Secondary Contact Name

First NameMiddle NameLast Name
Secondary Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
Secondary Contact Email
example@example.com
DOT Program Information
Currently enrolled in a random drug and alcohol consortium?
Current C/TPA company name
Switching from another consortium?
FMCSA Clearinghouse registered?
Need assistance with Clearinghouse registration?
DOT modes regulated under
Random Testing Information

Please Just fill out as much as you can
Total number of CDL drivers to enroll
Total number of safety-sensitive employees
Are any drivers owner-operators?
Are there any drivers in Return-to-Duty or Follow-Up Testing?
If yes, list driver name(s) and SAP information
Please list the full name number and email for the DER (Designated Employer Rep)
Employer Acknowledgements
Acknowledgement of ClearHive Screenings role as a Third-Party Administrator (C/TPA) and that hiring decisions remain the company’s responsibility
Acknowledgement that the company is responsible for maintaining compliance with all applicable DOT regulations
Authorization for ClearHive Screenings to manage random selections and testing coordination on behalf of the company
Acknowledgement that signed donor authorizations are required when applicable
Acknowledgement that pricing may vary based on services selected and employee count
Agreement to maintain updated driver and contact information
Signature Section
Authorized Representative Name

First NameLast Name
Title
Signature
Date

MonthDayYear
Date
Additional Service Questions
After-hours testing support
Nationwide testing coverage
Assistance setting up a company drug & alcohol policy
Employee educational materials
Should be Empty:

C/TPA Enrollment Form

Company Information

Primary Contact Information

DOT Program Information

Random Testing Information

Employer Acknowledgements

Signature Section

Additional Service Questions