DER Certification Renewal

Part 1: Company Information
(as printed on renewal form sent to you):
Company Name
Primary Email
if any inforrmation on page 1 of the DATIA renewal form is not accurate, please correct in next section.
Please add current email. Fields in Red are required values.
Corrections and additions to the information on the DATIA Form
Primary Contact Name
Company Name
Address
City
State
Zip
Phone
Fax
Web
Other changes or 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 DER Certification Rules

Part 2: Renewing DER Recertification Registration
DER Renewal Exam #1
Name
Email (for exam results)
Date Trained
Name of DER Trainer
Trainer Email
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.)
Corrections to Renewal Form?
name
address same as company? Yes No
address
phone fax
city
state
zip
DER Renewal Exam #2
Name
Email (for exam results)
Date Trained
Name of DER Trainer
Trainer Email
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.)
Corrections to Renewal Form?
name
address same as company? Yes No
address
phone fax
city
state
zip
DER Renewal Exam #3
Name
Email (for exam results)
Date Trained
Name of DER Trainer
Trainer Email
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.)
Corrections to Renewal Form?
name
address same as company? Yes No
address
phone fax
city
state
zip
DER Renewal Exam #4
Name
Email (for exam results)
Date Trained
Name of DER Trainer
Trainer Email
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.)
Corrections to Renewal Form?
name
address same as company? Yes No
address
phone fax
city
state
zip
Part 3: 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 4: Totals

Description

Number

Cost

Amount

1. Recertification Exams for DERs
2. DER Applicant Exams for DER Certification Status
3. Manual

TOTAL


Part 5: Payment Information
Promo Code:
Enter your promo code here. Discounts based on your promo code
will be applied before payment is processed.
Payment Type:

MC
VISA
AMEX
Card #
Cardholder's Name
Exp. Date
This is a secure order form but if you prefer to print this out our Fax (202) 315-3579

Check payments should be mailed to DATIA • 1325 G Street, NW, Suites 500-5001 • Washington, DC 20005


REFUND/TRANSFER POLICY: No refunds are offered for DATIA certification exam registrations once payment is submitted. In addition, no transfer of registrants is allowed as the original registered candidates(s) retains access to the exam registration

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