Drug and Alcohol Testing Industry Association 1325 G Street, NW, Suite 500#5001 Washington, DC 20005 800.355.1257 (p) 202.315.3579 (f) datia.org firstname.lastname@example.org
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1. Please provide a history of your urine drug screen specimen collection employment history. If extra space is needed,
please submit on a separate typed sheet. This space must be filled out even if this information is contained in your
Dates of Employment: Supervisor Name:
Employer Phone: Employer Fax:
Summary of Work performed (i.e. average number of collections per week, other duties, etc.)
2. Please list any continuing education in the field of drug and alcohol testing and/or presentation skills that you have
attended in the previous 12 months.
Title of Course: Date:
Offered By: Length:
3. Please detail your experience in making presentation and training collectors in specimen collection. If extra space is
needed, please attach a separate typed sheet. This space must be filled out even if this information is contained in your
Title of Presentation:
Date of Presentation: Audience for Presentation:
4. I, , attest that I agree to abide by the R-CPCT program polices and guidelines as
stated in the previous section of this application. I also understand that as the R-CPCT program evolves, these policies
and guidelines may change. DATIA will notify me of these changes and I agree to abide by any new or changed policies
and guidelines. I further attest that I understand that should I violate any of the certification program’s policies and
guidelines, the violation will be reviewed by DATIA’s Executive Director and/or Specimen Collections Committee and
appropriate action will be taken that may include revocation of my R-CPCT certification.
5. Please include the following attachments with your R-CPCT application. Applications will not be considered without
the required attachments, and applicants will not be contacted to complete incomplete applications.
1. Current Resume or Curriculum Vitae
2. Letter stating what you feel your experience and qualifications can bring to the DATIA Collector Certification
3. Letter of recommendation from two collectors to whom you have provided training.
4. Letter of recommendation from one person (client or supervisor) who can attest to your proficiency in specimen
I attest that I and my company continue to adhere to the standards of the RCPCT program, and that I continue to uphold the highest standards in administration of my clients' drug and alcohol testing programs.
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