Drug & Alcohol Online Application

Step 1 of 3

Company Name*
DOT Number
Contact Person*
(Designated Employer Representative)
Title*
Email
Phone*
Fax
Number of Drivers*
Are you currently a member of the MMTA?*
- Yes
- No
- I'm not sure
PHYSICAL LOCATION
Address (Physical Location)*
Street Address Address Line 2 City State ZIP / Postal Code Country
Mailing Address (If different than physical Location)
Street Address Address Line 2 City State ZIP / Postal Code Country

PROGRAM IMPLEMENTATION
Preferred Method of Receiving Test Results*
Payment Information*
ADD DRIVERS
(Please type names, DOB's, CDL License and State of Issuance for EACH employee)
If you prefer to upload a file (preferably Excel) instead of listing drivers individually, please click on the "Browse" button below to select a file from your computer.
Max. file size: 32 MB.
Click HERE to download template to send
To upload drivers individually, please list them. If you have more than 10 drivers, please use Excel upload feature above:
I acknowledge that FMCSA regulations require all drivers undergo pre-employment testing, or to meet the exception in 49 CFR PART 382.301(b), as part of enrolling in the random testing program.*
- Yes, I understand
Once acknowledgement box is checked, you will be able to list your drivers.
How many drivers would you like to register?*
Please enter a number from 0 to 10.
(Form limit is 10 drivers)
Name of Driver #1*
Driver #1 Date of Birth*
Month
Day
Year
Driver #1 - CDL License #*
Driver #1 - CDL State of Issuance*
Name of Driver #2*
Driver #2 Date of Birth*
Month
Day
Year
Driver #2 - CDL License #*
Driver #2 - CDL State of Issuance*
Name of Driver #3*
Driver #3 Date of Birth*
Month
Day
Year
Driver #3 - CDL License #*
Driver #3 - CDL State of Issuance*
Name of Driver #4*
Driver #4 Date of Birth*
Month
Day
Year
Driver #4 - CDL License #*
Driver #4 - CDL State of Issuance*
Name of Driver #5*
Driver #5 Date of Birth*
Month
Day
Year
Driver #5 - CDL License #*
Driver #5 - CDL State of Issuance*
Name of Driver #6*
Driver #6 Date of Birth*
Month
Day
Year
Driver #6 - CDL License #*
Driver #6 - CDL State of Issuance*
Name of Driver #7*
Driver #7 Date of Birth*
Month
Day
Year
Driver #7 - CDL License #*
Driver #7 - CDL State of Issuance*
Name of Driver #8*
Driver #8 Date of Birth*
Month
Day
Year
Driver #8 - CDL License #*
Driver #8 - CDL State of Issuance*
Name of Driver #9*
Driver #9 Date of Birth*
Month
Day
Year
Driver #9 - CDL License #*
Driver #9 - CDL State of Issuance*
Name of Driver #10*
Driver #10 Date of Birth*
Month
Day
Year
Driver #10 - CDL License #*
Driver #10 - CDL State of Issuance*
Your Company's Collection Site(s)
For a list/map of preferred and non-preferred collection sites, please go to www.mmta.com/drugandalcohol
Please list each collection site:*

Drug & Alcohol Online Application

Step 1 of 3

PHYSICAL LOCATION

PROGRAM IMPLEMENTATION

ADD DRIVERS

Your Company's Collection Site(s)

ACKNOWLEDGEMENT