CONSORTIUM/RANDOM TESTING ENROLLMENT

RELIABLE & ACCURATE RESULTS

Palmetto Testing is the trusted lab screening partner for many businesses, schools, court systems, DOT-regulated organizations and corporations. Fill out the form below.

    Date:

    Company Name:

    New

    Reinstatement

    Main Contact Name:

      Billing Contact: Same

    Mailing Address:

    Physical Address: Same

    Billing Address:Same

    City, State, Zip

    City, State, Zip

    City, State, Zip

    Email:

    Who Referred You?

    # Of Employees:

    Authorized to receive drug screen results and preferred method: (Please list below or attach in a separate pdf).

      phone/fax/email:

      phone/fax/email:

      phone/fax/email:

     

     

     

    Type Of Business:

     

    Employee Name

    Employee ID#/CDL# & State

     

    Are you currently enrolled in a Random Drug Testing Program?

    Yes

    No

    If Yes, Consortium Name:

    Type of testing your company requires:

    DOT

    Non-Dot

    Would you like us to help with your FMCSA Clearinghouse requirements?

    Yes

    No

    Please Note: All DOT Employees Must Provide Proof Of a Negative Drug Test, or Previous Consortium Enrollment, Before They Will Be Enrolled In The Consortium Program.
    To Use A Previous Drug Test, It Must Have Been Taken Within 30 Days Prior To Joining The Consortium

    With my signature, I hereby agree to participate in Palmetto Testing consortium and further agree to abide by its rules, policies and procedures. Upon receipt of my signed application and payment, Palmetto Testing will forward me a complete membership package, which will include proof of membership and rules and regulations.

    Authorization Signature:

    Date: