PLEASE SELECT SERVICES REQUIRED

Please select services required:

Drug & Alcohol Testing Services *

Select Drug Screen Type(s): *

DOT

NON-DOT

BOTH

DOT MODE: *

How would you like Results/Reports sent? *

Secure Email

Secure Fax

Web Login

Would you like Chemnet assistance with the Clearinghouse? *

What is your DOT number? *

Are you under audit?

Drug and Alcohol Policy Service *

Which Employees should the policy apply to? *

Disciplinary action for Positive test result? *

How should Negative Dilute samples be treated? *

Who will approve the policy? *

**DOT and most State laws require a drug and alcohol policy.

Random Selection Service *

Selection pool information *

Supervisor Training Services *

Just a note to Owner/Operators: there will be a lot of spammers that will try to sell you Supervisor Training on Reasonable Suspicion once they see you registered for a DOT number. You are not required to have this training as an Owner/Operator. Once you employ another driver, the training is mandatory. If you need training in the future, please let us know and we can help facilitate that for you!

For all others: This training is MANDATORY by both State and Federal Regulations

Employee Background Services *

Designated Employer Representative (DER)

DER Name: * 🛈

DER Phone # *

DER Email Address: *

Will the DER be included in the Random Testing Pool? *

If "YES", Please ADD the DER as an employee in the form below.

Additional contact person (1)

Phone #

Email Address:

Privileges for this contact.

Quarterly Random Selections

Drug Test Results

Additional contact person (2)

Phone #

Email Address:

Privileges for this contact.

Quarterly Random Selections

Drug Test Results

Employee(s) to be added to random selection pool

** If you are adding more than 5 employees, please contact us for a seperate form **

Employee Name *

MODE *

Employee ID *

CDL Driver License # *

State: *

Pre-Employment test date? 🛈 +

ADD More?

Employee Name *

MODE *

Employee ID *

CDL Driver License # *

State: *

Pre-Employment test date? 🛈 +

ADD More?

Employee Name *

MODE *

Employee ID *

CDL Driver License # *

State: *

Pre-Employment test date? 🛈 +

ADD More?

Employee Name *

MODE *

Employee ID *

CDL Driver License # *

State: *

Pre-Employment test date? 🛈 +

ADD More?

Employee Name *

MODE *

Employee ID *

CDL Driver License # *

State: *

Pre-Employment test date? 🛈 +

Special Notes

Contract For Services:

The Chemnet Consortium Inc. will provide the following drug/alcohol testing services to
customers.

1) All billing for annual random selection, lab testing, MRO services, collection (using
designated Chemnet collection sites) and transportation of samples will be billed to
customer by The Chemnet Consortium Inc. All bills will be paid to The Chemnet
Consortium Inc. within 30 days of the invoice date.

2) If random selection services apply the percentage of the pool to be selected and
frequency of the selections will be determined by Federal Regulations or as requested
by the customer.

3) It is the customer’s responsibility to ensure The Chemnet Consortium Inc. receives
current employee changes and updates for your company, to be included in the random
program. It is also the customers responsibility to ensure any employees selected for
random testing are tested before the deadline provided in the documentation sent by
The Chemnet Consortium each quarter of the year.

4) The customer will not be charged for samples that are rejected due to collection errors.

5) An annual random fee will be charged every year based on the number of employees the
customer has in the random program. (see price list) Random selection will be done by
The Chemnet Consortium Inc of Billings using the scientific method of computer driven
random number generator. Only the designated contact person listed on the customers
enrollment form will receive the written notice of any employee who is selected for
testing.

6) University Services will be the Medical Review Officer. Results will be provided based on
the customer’s request of the following, secure fax, email or internet. Clinical Reference
Laboratories is our primary lab for certified testing.

7) The term of this contract shall be for 1 year commencing the date execution. The
contract may be renewed with the written consent of both parties. This contract may
be terminated by either party without cause by giving the other party thirty (30) days
written notice of termination. This contract may be immediately terminated by either
party with cause (cause being a violation of the contract provisions) by giving the other
party written notice. If no written notice to renew or cancel is given by either party
after one year, the contract will automatically renew for one more year and every year
thereafter in which no written notice is given by either party.

The terms and conditions of this contract will apply for all customers who have completed an enrollment for services offered by The Chemnet Consortium Inc.

Contract for Service *

clear

Desk Top Computer - sign with mouse

Tablet or phone - sign with your finger

Printed Name: *

Date: * +

Support

If you have additional questions or concerns, please feel free to contact us (406) 256-2037 or Email us at: Support@mtchemnet.com

Please note that with any changes you make to your account with us, you should recieve a response from our staff within (3) business days. If not, please contact us directly to verify your changes have been made.

COMPANY INFORMATION

PLEASE SELECT SERVICES REQUIRED

Designated Employer Representative (DER)

Employee(s) to be added to random selection pool

Support