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:*

ACKNOWLEDGEMENT
Yes, I agree*
By submitting this application, I hereby acknowledge that I agree to the terms of the MMTA Drug & Alcohol Program.
Members of the drug and alcohol testing pool agree to the following terms:

Initial application fee of $50 for MMTA members and $100 for non-members of MMTA.

Annual fee of $25 for MMTA members and $50 for non-members of MMTA. An annual renewal fee of $25/members or $50/non-members will be invoiced each year by our TPA partner.

Members of the Drug and Alcohol Program agree to:

1. To pay C/TPA, MMTA, or any service provider for services rendered as part of the program;
2. To update company information with MMTA and C/TPA if changes are made to address, contact, or other company information;
3. To add or delete drivers with C/TPA as employees are hired or terminate employment; and
4. To test as selected, prior to the end of each selection period and to release C/TPA and MMTA from any liability due to company’s failure to complete required testing.

Members agree to coordinate directly with our service provider for testing supplies and chain of custody forms.

Drug & Alcohol Online Application

Step 1 of 3

PHYSICAL LOCATION

PROGRAM IMPLEMENTATION

ADD DRIVERS

Your Company's Collection Site(s)

ACKNOWLEDGEMENT