Application For Certification Of Drug-Free Workplace Premium Credit Program printable pdf download

Application For Certification Of Drug-Free Workplace Premium Credit Program

APPLICATION FOR CERTIFICATION OF

DRUG-FREE WORKPLACE PREMIUM CREDIT PROGRAM

DIRECTIONS: After reading the Department’s Administrative Rules and the Drug-Free

Workplace Program Guide, please complete the following checklist and return only this checklist

and a $25.00 check for the certification fee to the address below. Keep the documentation of

your compliance in your files for review upon request by your insurer or the Department of

Labor, Workers' Compensation Division.

Alabama Department of Labor

Finance Division

Attn: Central Cashier

649 Monroe Street

Montgomery, Alabama 36131

Drug-Free Workplace Coordinator:_________________________________________________

Company:_____________________________________________________________________

Address:______________________________________________________________________

_____________________________________________________________________________

Phone number: ( _ )

Number of Employees: ___________________

Email Address: _____________________________

This is our company's first year of application for certification as a drug-free workplace.

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TO BE COMPLETED BY THE DEPARTMENT OF LABOR, WORKERS'

COMPENSATION DIVISION.

Date of First Certification:_________________________

Approved By:__________________________________

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Application For Certification Of Drug-Free Workplace Premium Credit Program