DATIA New DER Certification Application

Part 1: Company Information
Company Name
Primary Contact Name
Primary Email
Address
City
State
Zip
Phone
Fax
Web
Notes

Program Rules and Regulations:

  • Only DERs that meet the CDER pre-requisites and attend a DER Compliance Course are eligible to receive the CDER designation and train other DERs.
I agree to abide by all DATIA Certification Rules
Part 2: New DER Registrations
New DER Exam Registration #1
Name
Email (for exam results)
Date Trained
Name of Trainer
Trainer Email
address same as company? Yes No
only complete if no is checked above
address
phone fax
city
state
zip
I understand that a C-DER certificate applies only to DERs or assistants to the DER within the company's drug & alcohol testing program. (Note regulation §40.15(d) that states that service agents are prohibited from acting as DERs under any circumstances.)
New DER Exam Registration #2
Name
Email (for exam results)
Date Trained
Name of Trainer
Trainer Email
address same as company? Yes No
only complete if no is checked above
address
phone fax
city
state
zip
I understand that a C-DER certificate applies only to DERs or assistants to the DER within the company's drug & alcohol testing program. (Note regulation §40.15(d) that states that service agents are prohibited from acting as DERs under any circumstances.)
New DER Exam Registration #3
Name
Email (for exam results)
Date Trained
Name of Trainer
Trainer Email
address same as company? Yes No
only complete if no is checked above
address
phone fax
city
state
zip
I understand that a C-DER certificate applies only to DERs or assistants to the DER within the company's drug & alcohol testing program. (Note regulation §40.15(d) that states that service agents are prohibited from acting as DERs under any circumstances.)
New DER Exam Registration #4
Name
Email (for exam results)
Date Trained
Name of Trainer
Trainer Email
address same as company? Yes No
only complete if no is checked above
address
phone fax
city
state
zip
I understand that a C-DER certificate applies only to DERs or assistants to the DER within the company's drug & alcohol testing program. (Note regulation §40.15(d) that states that service agents are prohibited from acting as DERs under any circumstances.)


Part 3: Totals

Description

Number

Cost

Amount

1. DER Applicant Exams for DER Certification Status
2. DER Applicant Exams for DER Certification Status
2. Manual

TOTAL


Part 4: Payment Information
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Card #
Cardholder's Name
Exp. Date
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