New Account Setup Form | Carolina Testing - Drugs | Alcohol | DNA

New Account Setup Form

- Step 1 of 5

Company / Organization Name *

Customer Type *

DOT Only
NONDOT Only
DOT and NONDOT

US DOT Number

DOT agency

Are You an Owner Operator?

Approximate Number of Regulated Employees *

1-20
20-99
100+

Enter the number of federally regulated employees (e.g.: CDL Drivers)

Owner/Operator Name *

First

Last

Drivers License Number *

Date of Birth

State of Issue for Drivers License *

Physical Address *

Address Line 1

Address Line 2

City

State

Zip Code

Is the mailing address the same as the physical address?

Mailing Address

Address Line 1

Address Line 2

City

State

Zip Code

Please provide the mailing address for billing purposes in this section.

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Designated Employer Representative (DER) *

First

Last

This is the main contact person who will be authorized to order services and receive confidential test results.

DER Email *

DER Office Phone *

DER Mobile Phone *

DER Secure Fax

This fax must be a secure fax if it is to be used for receiving drug test results.

Is there another person you would like to add to the account to be able to order services and/or receive results?

Authorized Representative *

First

Last

This is the main contact person who will be authorized to order services and receive confidential test results.

Authorized Representative Email *

Authorized Representative Phone *

Authorized Representative Access *

Order Services
Receive Results
Discuss Personnel Matters

Please choose all areas your authorized representative is permitted access to.

the (DER) Phone

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Is the billing contact the same as the DER? *

Billing Contact *

First

Last

Billing Email *

Billing Phone *

Billing Terms

I Agree To The Terms & Conditions Below
I DO NOT Agree

All invoices are emailed. Requests to have invoices submitted in any other format will be charged an additional $25 per invoice submitted via alternative methods (eg: mail, company portal). Billing terms are Net 30 days. Payments not received within 45 days of invoice date will incur a $25.00 late fee plus interest of 18% per annum until paid in full. Payments not received within 60 days of invoice date will be subject to service suspension and collection activities. All collection and legal fees incurred in an attempt to collect on invoices will be added to the account in addition to ongoing finance charges.

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SERVICE SELECTIONS

Choose all services that your company will need for this account. You can select more than one service in each category. Please refer to your confidential service and fee schedule for pricing.

DRUG & ALCOHOL TESTING

DOT Drug & Alcohol Testing
NONDOT 5 Panel Urine Drug Test (Lab Based)
NONDOT 10 Panel Urine Drug Test (Lab Based)
NONDOT 5 Panel RAPID Urine Drug Test
NONDOT 10 Panel RAPID Urine Drug Test
NONDOT 5 Panel Oral Saliva Drug Test (Lab Based)
NONDOT 9 Panel Oral Saliva Drug Test (Lab Based)
NONDOT 5 Panel Hair Follicle Drug Test (Lab Based)
NONDOT 10 Panel Hair Follicle Drug Test (Lab Based)
Breath Alcohol Testing

RANDOM TESTING PROGRAM MANAGEMENT *

No Random Testing Needed
DOT Consortium (Under 20 Drivers)
DOT Dedicated Pool (20+ Drivers)
NONDOT Dedicated Pool

Did you know that random drug testing provides for a 5% discount on worker's compensation premiums in the state of SC?

Random Pool Management Terms & Conditions *

I Agree To The Terms & Conditions Below
I DO NOT Agree

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.

BACKGROUND CHECKS

National Background Check
Motor Vehicle Records Check
State Specific Background Check
County Background Check
Credit Check*

*Credit Checks require special handling and set up fees.

OCCUPATIONAL HEALTH

DOT/CDL Physical
Basic Pre/Post Employment Physical
Advanced Pre/Post Employment Physical
SILVER Pre/Post Employment Physical
GOLD Pre/Post Employment Physical
PLATINUM Pre/Post Employment Physical
Pulmonary Function Testing
Respirator Fit Test (Qualitative)
PPD Tuberculosis Test
Clinical Bloodwork

NOTES or ADDITIONAL SERVICES REQUESTED

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Signature *

Clear Signature

By entering/signing my name into this document, I affirm that I am an authorized agent of the company and have full and complete authority to enter into this agreement. I agree to adhere to and be subject to the terms and conditions contained in this document.

Date *

Account Setup Fee *

Price: $50.00

One Time Account Set Up Fee: Fee includes set up of the company into a DOT qualified random drug and alcohol testing program.

Annual Random Management Fee *

Jan-Mar - $149.00
Apr-Jun - $111.75
Jul-Aug - $74.50
Sep-Dec - $37.25

Choose the month that you are enrolling into the program.

The Annual Random Management Fee is prorated for the first year based on the annual fee of $149 for companies under 20 drivers. This fee automatically renews on January 1 each year until cancelled.

Annual Random Management Fee *

Jan-Mar - $199.00
Apr-Jun - $149.25
Jul-Aug - $99.50
Sep-Dec - $49.75

Choose the month that you are enrolling into the program.

The Annual Random Management Fee is prorated for the first year based on the annual fee of $199 for companies with 20 to 99 drivers. This fee automatically renews on January 1 each year until cancelled.

Annual Random Management Fee *

Jan-Mar - $249.00
Apr-Jun - $186.75
Jul-Aug - $124.50
Sep-Dec - $62.25

Choose the month that you are enrolling into the program.

The Annual Random Management Fee is prorated for the first year based on the annual fee of $249 for companies with over 99 drivers. This fee automatically renews on January 1 each year until cancelled.

Total

$0.00

PayPal Commerce *

Card Number

Expiration Date

Security Code

Card Holder Name

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Enter your email address to receive the link via email. Alternatively, you can copy and save the link below.

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Email *