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

Company / Organization Name *

Physical Address *

Address Line 1

Address Line 2

City

State

Zip Code

Is the mailing address the same as the physical address?

Yes
No

Mailing Address

Address Line 1

Address Line 2

City

State

Zip Code

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

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.

Receive Drug Test Results Via *

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

Yes
No

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.

Is the billing contact the same as the DER? *

Yes
No

Billing Contact *

First

Last

Billing Email *

Billing Phone *

Receive Invoices Via *

Billing Terms Requested *

All billing is generated on a monthly basis for the prior month services.

Automatic Credit Card Payment

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

By 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 Terms

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

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.

FOR DOT REGULATED COMPANIES ONLY

For DOT regulated companies, please indicate your DOT agency:

US DOT Number (If applicable)

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

RANDOM TESTING PROGRAM MANAGEMENT *

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

Did 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 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

*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
Respirator Fit Test (Qualitative)

NOTES or ADDITIONAL SERVICES REQUESTED

Authorized 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 *

Date

Time