BY FILLING OUT AND SUBMITTING THIS FORM, I HEREBY SELECT NIRVANA MULTI SERVICE CENTRE LLC AS MY DESIGNATED CONSORTIA/ THIRD -PARTY ADMINISTRATORS (C/TPA)IN THE FMCSA COMMERCIAL DRIVER'S LICENSE DRUG AND ALCOHOL CLEARINGHOUSE. I ACKNOWLEDGE THEIR WILL BE A QUERIES INTO MY TRUCKING HISTORY AND DRUG TESTING RANDOMLY. I ACKKNOWLEDGE MY C/TPA MUST REPORT MY RESULTS TO THE FMCSA.
I AM AWARE THAT IF I REFUSE TO DO THE TESTING, MY C/TPA MUST REPORT IT TO THE FMCSA.
IF I HAVE ANY POSITIVE READINGS I ACKNOWLEDGE THAT I MUST COMPLY WITH THE PLANS BEFORE RETURNING TO DUTY TO DRIVE, AND RECORDS ARE REPORTED TO THE FMCSA.