Random Enlistment Request (Consortium)

This form is for companies wishing to enroll in the Random Enlistment Program (Consortium). Once a form is received, a Valley Day and Night Clinic representative will contact the Designated Employer Representative (DER) within 5 business days. If you have any questions, please contact Charlie Canizales at corporate@vdnclinic.com or by phone at (956)589-7156.

***Employee representative is responsible to immediately inform Valley Day & Night Clinic if an employee is not active with the company or if a new employee needs to be added to the driver list. If employer does not comply company will be removed from Random Program and will need to

register again, registration fees will reapply no exceptions.

Random Enlistment Fee $150.00 Yearly

DOT Drug Test $50.00 Per Drug Test

DOT Breath Alcohol Test $30.00 Per BAT


Company Information

Company Name*

Company Address*



Zip Code*

Office Phone*

Office Fax

Employee Representative Contact Information

Designated Employer Representative (DER)*

DER Phone*

DER Mobile*

DER Email*

I understand that there will be a yearly fee of $150.00 when entering into the Random Enlistment Program (Consortium).

I understand that failure to fill out this form correctly or completely may result in a delayed response from the Valley Day and Night Clinic corporate office.

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