National Association of Drug Free Workplaces (NADFW)

MEMBER APPLICATION:

_____________________________________________________________________________________________________________

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:

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:

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