Application For Voluntary Drug-Free Workplace Program {HS-36-A}

Form HS-36-A Ark. Code Ann. §1114-101 & AWCC Rule 36 Rev. 7-1-2010 ARKANSAS WORKERS' COMPENSATION COMMISSION HEALTH & SAFETY DIVISION 324 Spring Street, Little Rock, AR 72201 Mail: P. O. Box 950, Little Rock, AR 72203-0950 501-682-3930 / 1-800-622-4472 HS36-A Application for Voluntary Drug-Free Workplace Program Application Type: `Initial/first time application `Renewal (Approval no._______) Company Information 1) Company name: 3) City: 6) FEIN: 9) Company contact: 11) Title: 7) NAICS: 2) Address: 4) State 5) Zip: 8) Effective date of drug-testing program: 10) Telephone no.: ( 12) e-Mail: `Purchase (WCI) ) ` Termination of Participation 13) Workers' compensation insurance (WCI) status: `Self-insured 14) Insurance carrier or third party administrator (TPA): 15) Average number of employees during the most recent calendar year: 15a) Full-time: 15b) Part-time: Drug Testing Program Program Manager or Third Party Administrator 16) Name: 17) Address: 18) City: 19) State: 20) Zip: 21) Telephone no. 22) E-Mail: Testing Lab: 23) Name: 24) Address: 25) City 26) State: 27) Zip: 28) Telephone no.: ( ) 29) Certification No. (enter lab certification no; only one is required) SAMHSA: MRO: 32) City: 36) MRO certification no.: 30) Name: 33) State: 34) Zip: 31) Address: CAP-FUDTAP: Other: 35) Telephone no.: ( ) 37) If not certified MRO, other qualifying certification (please attach explanation describing how this meets the Rule 36 requirements for an MRO): HS-36-A American LegalNet, Inc. www.FormsWorkFlow.com (38) Summary Statistics Please attach the most recent year-end summary report from your testing laboratory or a letter certifying that no tests were required to be performed and why (no hires, no accidents, etc.). Employer Certification (complete for all applications) I certify the above information is, to my best knowledge, true and accurate. I further certify that I understand submitting false information on this application may constitute workers' compensation fraud (Ark. Code Ann. §11-9-106). I certify that at each of the above mentioned locations a drug-free workplace program has been put in place which is in full compliance with the requirements of AWCC Rule 36. (39)__________________________________________________________________________ Signature of Owner/Officer and Title ________________________ Date (40)__________________________________________________________________________ _________________________ Notary/Date and State of Commission Date The completed and notarized application should be sent to: Voluntary Drug-Free Workplace Program Health and Safety Division Arkansas Workers' Compensation Commission P.O. Box 950 Little Rock, AR 72203-0950 HS-36-A American LegalNet, Inc. www.FormsWorkFlow.com