Step One.

Existing DFW: Yes No      Certified by state for Insurance Discount: Yes No

(If yes:)
Year:   State:

A FOLLOW UP QUESTIONAIRE WILL BE SENT TO EACH MEMBER TO OBTAIN MORE INFORMATION


Company Name:   Date:


Your name:   Title:

Address:
City:         State:  Zip Code:

Work Number: 
Work Fax:       
Cell:                
Email:             
Website URL:  



Number of Employees
F/T: P/T:



Best Person to contact:
                            Title:
                         Phone:


WHICH OF THE FOLLOWING DOES YOUR COMPANY PRESENTLY DO (Select all that apply)

DRUG TESTING:
Drug Free Workplace:       
Pre-employment               
Random                           
For Cause                        
Accident/Incident:             
Use Outside Vendor or Lab  Vendor(s) Name:



BACKGROUND CHECKS:
Pre-employment:      
SSN:                       
Criminal:                  
Civil:                        
Motor Vehicle:          
Education:               
Employment:           
Credit:                     
Use Outside Vendor:  Vendor(s) Name:



COMPANY NEEDS:
Workers Comp. Insurance:          
Drug Free Discount:                       
Safety Program Discount Insurance:
Self Insurance:                               
Health:                                          
Liability:                                        
Premises:                                     
Financial:
Commercial Collection Services:     
Special Needs:



Step Two: Determine Your Membership Category


Dues & Fees List

Regular Member  $149.00 per year  Primary State:

Additional States (Up to TEN) $49.00/each.
Please List:
1: 2: 3: 4: 5: 6: 7: 8: 9: 10:

Over TEN states (Unlimited) $500/year.



To determine Membership Category & Annual Dues Check the appropriate box below:

Base Fee$149.00

Up To Ten States:
# of States   x $49.00=   $
Over Ten States $500:              
TOTAL:                                     



Note: Each Employee is eligible to receive the NADFW Certification & Benefits ID Card. This card is voluntary and includes a Drug Test and Criminal Background Check. The initial cost to employees of NADFW members is $79.00 each with an annual renewal cost of $49.00 which includes a drug test and background check update. Contact NADFW for more information.



Special Needs:
THIS FORM CAN BE FAXED TO:
407-949-5699