|
NTA ID # [To be issued]
____________
Driver/Applicant Drug
Program Registration Form
Please Print - Every
Line must be Completed
For Faster
Service- Always PRE-REGISTER the person by FAXING IN this REGISTRATION
FORM to
800 810-6998 or local California (562) 279-0566 before the Person goes
to the Collection Site.
Program I –
Single person Program II – Fleets of two or more
NOTE:
US DOT regulations state that Each Applicant must have two hours of
documented training in both Drugs and Alcohol. An Official Driver
Compliance Training Book will be automatically billed at the rate of
$17.95 and sent to the company unless you opt out. WE WILL NOT BE
RESPONSIBLE FOR ANY FINES. Our company does not need the training book.
Driver/Applicant Information
Full Name as shown on License :________________________________________________________________________
Address
___________________________________________________________________________________________
City/State/Zipcode
__________________________________________________________________________________
SS# ____________________________ Date of Birth
_________________Phone ( ) ________________________
Driver Lic _____________________________
o Class A
o Class B -
o Class C Non-DOT Pool
DER Name:
_______________________________________________ Tel No: ________________
Company _______________________________________ US
DOT No. ___________________ NTA Co ID # ________
Address/City/State
____________________________________________________________________________________
Rev: 1/1/08 |
