CMCI Registration

Motor Carrier Information

Member Number

USDOT#

Company Owners Name

Company Name:

Mailing Address

Street Address Address Line 2 City State ZIP Code

Phone

Cell Phone

Email

Fax

Driver Information

Member Number

Driver Name

Mailing Address

Street Address Address Line 2 City State ZIP Code

Home Phone

Cell Phone

Date of Birth

Email

Registered in the clearinghouse

Yes
No

Does this driver hold a CDL?

Yes
No

CDL Number

State Issued

State

Attach a copy of CDL

This drive is an

Number of Trucks Owned

Please enter a number from 0 to 100.

Own a Trailer

Yes
No

Has driver ever tested positive OR refused a controlled substance screen?

Yes
No

Did driver complete Return to Duty Process?

Yes
No

Can driver provide SAP/Return to Duty information to the Motor Carrier?

Yes
No

Designated Employer Representative Information (DER)

The DER will receive correspondence from CMCI regarding drug and/or alcohol testing, selection notices, results and has the authority toremove a driver from safety sensitive functions if the driver tests positive or refuses drug and or alcohol testing

Add DER

Name of DER:

Mailing Address

Street Address Address Line 2 City State ZIP Code

Phone

Email

Pre-employment drug test, In accordance with §382.301

I would like CMCI to set up the pre-employment drug test. Pre-employment drug testing is an additional fee and is not included in the CMCI yearly random testing fee. Results will be provided directly to the DER. You must receive negative results before the driver performs safety sensitive functions. Payment for the test will be collected by CMCI at the time test is scheduled.
I will set up the test on my own and send CMCI the results. The DER or Company will set up and pay for the pre-employment drug screening at a facility of their choice that performs DOT regulated drug screenings. You must receive negative results before the driver performs safety sensitive functions. Payment will be collected by the facility.
I have received written verification from my driver’s previous company and he/she qualifies for the pre-employment exceptions and does not need a pre-employment test at this time. Examples of written proof include verification from driver's previous employer that the driver has not been out of a random program for more than 30 days (from date of employment application) AND was drug tested within the previous 6 months OR was continuously enrolled in a random program for the previous 12 months.

By signing this form, I certify that the above information is true and correct to the best of my knowledge. I agree to comply with the drug and alcohol testing requirements of 49 CFR Part 40 and Part 382. I certify that I have read and agree to the CMCI service agreement and understand that a drug and or alcohol test will be performed at any time and manner required by the FMCSA regulations and CMCI policy.

By signing this form, I authorize CMCI to act as the intermediary for the purpose of transmitting all drug and alcohol testing information under the circumstances contained in 49 CFR §40.345 and as allowed under the provisions of Appendix F to 49 CFR Part 40.

Sign

Service Agreement

CMCI Registration

Motor Carrier Information

Driver Information

Designated Employer Representative Information (DER)

Pre-employment drug test, In accordance with §382.301

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