new account setup Use this online tool to get your account setup for services with Carolina Testing. Please enable JavaScript in your browser to complete this form.Company / Organization Name *Physical Address *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeIs the mailing address the same as the physical address?YesNoMailing Address Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePlease provide the mailing address for billing purposes in this section.Designated Employer Representative (DER) *FirstLastThis is the main contact person who will be authorized to order services and receive confidential test results.DER Email *DER Office Phone *DER Mobile PhoneDER Secure FaxThis fax must be a secure fax if it is to be used for receiving drug test results.Receive Drug Test Results Via *EmailSecure Online Web PortalSecure FaxIs there another person you would like to add to the account to be able to order services and/or receive results?YesNoAuthorized Representative *FirstLastThis 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 ServicesReceive ResultsDiscuss Personnel MattersPlease choose all areas your authorized representative is permitted access to. Is the billing contact the same as the DER? *YesNoBilling Contact *FirstLastBilling Email *Billing Phone *Receive Invoices Via *EmailMailBilling Terms Requested *Auto Credit Card PaymentNet 30 TermsAll billing is generated on a monthly basis for the prior month services.Automatic Credit Card PaymentI Agree To The Terms & Conditions BelowI DO NOT AgreeBy submitting and signing this document, I attest that I am an authorized user of the credit card provided for payment of services provided by Carolina Drug & Alcohol Testing Services, LLC (CDATS) or its assigns. I authorize CDATS to charge this designated credit card for the total amount due for services rendered on this account within 5 days of invoice generation. I agree to notify CDATS in writing of any changes to my account information or termination of this authorization at least 15 days prior to the next billing date. Unpaid invoices are subject to the terms & conditions of this agreement. 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. WE WILL CONTACT YOU VIA PHONE TO COLLECT THE CREDIT CARD INFORMATION TO BE PLACED ON FILE. DO NOT PUT CREDIT CARD INFORMATION IN THIS FORM.Net 30 TermsI Agree To The Terms & Conditions BelowI DO NOT AgreePayments 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.FOR DOT REGULATED COMPANIES ONLYFor DOT regulated companies, please indicate your DOT agency:FMCSAFTAFRAFAAPHMSAUSCGUS DOT Number (If applicable)SERVICE SELECTIONSChoose 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 TESTINGDOT Drug & Alcohol TestingNONDOT 5 Panel Urine Drug Test (Lab Based)NONDOT 10 Panel Urine Drug Test (Lab Based)NONDOT 5 Panel RAPID Urine Drug TestNONDOT 10 Panel RAPID Urine Drug TestNONDOT 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 TestingRANDOM TESTING PROGRAM MANAGEMENT *DOT Dedicated Pool (20+ Drivers)DOT Combined Pool | Consortium (Under 20 Drivers)NONDOT Dedicated PoolNo Random Testing NeededDid you know that random drug testing provides for a 5% discount on worker's compensation premiums in the state of SC?Estimated Number of Employees In Random Pool *Random Pool Management Terms & Conditions *I Agree To The Terms & Conditions BelowI DO NOT AgreeCompany 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 CHECKSNational Background CheckMotor Vehicle Records CheckState Specific Background CheckCounty Background CheckCredit Check**Credit Checks require special handling and set up fees.OCCUPATIONAL HEALTHDOT/CDL PhysicalBasic Pre/Post Employment PhysicalAdvanced Pre/Post Employment PhysicalSILVER Pre/Post Employment PhysicalGOLD Pre/Post Employment PhysicalPLATINUM Pre/Post Employment PhysicalRespirator Fit Test (Qualitative)NOTES or ADDITIONAL SERVICES REQUESTEDAuthorized eSignature *By entering 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 / Time *DateTimeNameSubmit16209