Sign-up Now!

Thank you for your interest in joining our Random Drug Testing Program. After completing this form a starter package will be sent to you within two business days along with either an invoice or credit card confirmation.

 

Please fill out the form below to become a participant in the program.  If you would like to read more details about the plan or prefer to view, print and mail us this form via the post office click here for a PDF version of the form.  All Fields marked with * are required to submit the form.
 

General Information:

Company Name:*

 

Address:*

 

City:*

State:*

Zip:*

Phone:*

 

Email:*

 

Designated Employer Representative(s):*

Representative #1:

Representative #2:

Collection Site:

Lakewood Clinic
5203 Lakewood Blvd.
Lakewood, CA. 90712

Commerce Clinic
6538 Telegraph Road
Commerce, CA. 90040

La Mirada Clinic
15330 Valley View Ave.
La Mirada, CA. 90638

Services:

Enrollment:

1. An annual enrollment of $100 and $30 per person per year. *
This choice includes all random drug and alcohol tests at no additional charge. If client is selected for testing through out the year, the tests are FREE.

All non-random Federal tests will be $50.  All non-random breath alcohol tests will be $15.

For more pricing options and packages, call now! (714) 443-0330
 

Persons Enrolled: *

Participant Information:

Please submit your company's participant information. All employees that are in safety sensitive positions should populate this list. To submit the information you may either:

1.  Email an excel file to administrator@consortiumcompliance.com
2.  Fax a current list to (714) 443-0299. Please make fax attention to Donna.
 

Supervisor Training:

  Call for class schedule and pricing.

DER Training:

  Call for class schedule and pricing.

E-Compliance Membership:

  $9/month   Sign up for a year and get a month FREE!

Billing Details:

Payment Type:

  Invoice (All invoices are due within 30 Days)

  Credit Card (By selecting this option we request that you fill in the card details below.  We will send an email confirmation with your final total before any charges are actually applied to your card.)

Name On Card:

Card Type:

Card Number:

Expiration:

Month (xx)    Year (xxxx)  

CSV:

  (Three Digit Code On Back Of Card.  For American Express It Is Four Digit Code Above Account Number To The Right)

Billing Address:   Same as above.

Billing Street:

 

Billing City:

 

Billing State:

Billing Zip:

 

Consortium Member Agreeement:

 * You acknowledge that there is an agreement between Consortium Compliance and you (the employer).  The following details are covered under this agreement.


 


 
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