FMCSA / DOT Drug & Alcohol Testing Consent Form

FMCSA / DOT Drug & Alcohol Testing Consent Form

Please fill out your company and driver information to complete the agreement.
Client Information
Company Name
DOT Number
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Authorized Representative Name
Email
example@example.com
Phone
Please enter a valid phone number.Format: (000) 000-0000.
Pricing Details
- DOT Drug Test: $75.00
- BAT In Office: $40.00
- BAT External Facility: $60.00
- Out-of-Network Fee: $25.00 + actual costs
- Direct Observation Collection: $15.00
- Shy Bladder Collection: $15.00
- MRO Review: $35.00
- Clearinghouse Setup: $100.00
- Post-Accident Testing Coordination: $150.00
- Reasonable Suspicion Testing Coordination: $150.00
- SAP Referral Coordination: $75.00
Membership Options
- 1-Year Membership: $99.00
- 2-Year Membership: $159.00
- 3-Year Membership: $199.00
Membership includes: Enrollment, random selections, testing notifications, annual compliance support, and record retention.
Membership Options
ATC C/TPA Services Include: Random testing program administration, FMCSA Drug & Alcohol Clearinghouse support, testing coordination, record retention, MIS reporting assistance, audit support, and compliance consulting.
Payment Terms: Client authorizes ATC to maintain a credit card or ACH authorization on file. Invoices are due upon receipt. Delinquent balances accrue interest at 1.5% per month (18% annually) or the maximum permitted by law.
Governing Law & Venue: This agreement is governed by Indiana law. Venue is exclusively in Marion County, Indiana.
Standard Agreement Clauses: Regulatory compliance, indemnification, limitation of liability, record retention/confidentiality, electronic signatures, term/automatic renewal with 60-day written notice, and attorney fees apply. Full agreement text provided upon request.
Driver Information
Signatures
ATC Authorized Representative Name
ATC Signature
ATC Date

MonthDayYear
Date
Client Authorized Representative Name
Client Signature
Client Date

MonthDayYear
Date
Should be Empty:

FMCSA / DOT Drug & Alcohol Testing Consent Form

Client Information

Signatures