Company Name:

DOT Number:

Authorized Representative Name:

Phone Number:

Email:

Driver Full Name:

CDL Number:

Issuing State:

Date of Birth:

ZIP Code for Drug Screen Location:

Are you replacing a driver?
Yes
No

Name of Replaced Driver:

IMPORTANT: FMCSA requires a negative pre-employment drug screen and a “not prohibited” Clearinghouse query before a driver can operate a CMV.

$179 – Full DOT Drug Program + Clearinghouse Support

$149 – DOT Drug Program Only (No Clearinghouse)

By submitting this form, you confirm that:

• You are authorized to add this driver
• The information provided is accurate
• Pre-employment drug testing is complete or scheduled

I have read and agree to these terms.