BRAVO Consortium Online Enrollment Form Company Name * Owner or Designated Employer Representative (DER) * First Last Mailing Address Address * City * State * Zip Code * Phone * Email Address * Add Alternate Contact? Yes No Alternate Contact First Last Alternate Phone Alternate Email Type of Operation * Owner-Operator Only Owner-Operator + Add'l Driver(s) Owner is NOT a Driver DOT # * Approximate # of Drivers Owner Operator Driver's License Information * License Number * State * Is your company registered with the FMCSA Drug & Alcohol Clearinghouse? Yes No I don't know Is your company currently enrolled in a random drug & alcohol testing program with another provider or C/TPA? Yes No Does your company have a DOT pre-employment drug test on file for all drivers including owner-operators? Yes No One Time Set Up Fee * Price: $25.00 Annual Enrollment Fee 1-5 Drivers - $50.00 6-20 Drivers - $75.00 21-50 Drivers - $125.00 50-99 Drivers - $175.00 100+ Drivers - $225.00 Total $ 0 Payment Method * PayPal TERMS & CONDITIONS: Company agrees to enlist the Consortium Third Party Administration (C/TPA) services provided by Carolina Testing for Random Pool Management. This service agreement is an annual (January 1st to December 31st) agreement which may be pro-rated in the initial term of this agreement. Agreement commences upon receipt of signed service agreement. Company may terminate services at any time in writing. Initial set up fee and annual membership fee is non-refundable. As the Designated Employer Representative or owner/operator of the Company, I hereby agree to the terms of this agreement and further acknowledge that random selections are required to be tested as selected within the timeframe allotted. I understand that Carolina Testing has the right to terminate our enrollment as a participant in the event of non-payment of services or failure to have testing completed as required. Department of Transportation (DOT) regulated owner/operators failing to respond to testing requirements (refusal to test) or testing positive for drugs or alcohol will be immediately removed from the consortium and such removal will be reported to DOT and any applicable agencies. This agreement will automatically renew and enrollment fees will be assessed on January 1st unless Company or Representative gives Carolina Testing written notice of desire to terminate this agreement, or this agreement is cancelled for any reason by Carolina Testing. It is understood and agreed that it is ultimately the Company's responsibility to stay compliant with DOT regulations. I have read and agree to the Terms and Conditions above.