KTHC DOT Service Agent Agreement According to the US Department of Transportation rules and regulations a company can have a service agent provide or coordinate the provision of a variety of drug and alcohol testing services to employers. Included in these regulations are requirements that the providers of the drug and alcohol C/TPAs and MROs are certified according to the standards and drug testing procedures required under 49 CFR Part 40. KTHC is compliant with all requirements required under 49 CFR Part 40. If your company is electing to have KTHC as your DOT Service Agent, Complete the form below.DOT Service Agent Year – 2025* New (After July 10, 2025 & Prior to October 10, 2025) Contract Term January 1 to December 31, 2025. This agreement expires 12/31/25 and will automatically renew for subsequent 12 month periods per the terms listed below.Name of Motor CarrierDo you have a DOT #? Yes No DOT NumberStreet Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Billing Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Fax*Please note that KTHC sends results, billing and informational documents to your email address. We request that your email be kept secure due to sensitive information that may be transmitted. Email*Random Selection ProviderKTHC is Random Selection Provider*Please circle “Yes” below if you would like for us to pull your random drug screens and alcohol selections. By selecting YES, Motor Carrier agrees to send a complete list of all drivers to KT Health Clinic when requested. Minimum will be each six months – December and June – for random selections. Yes No Conduct Clearinghouse Queries*Please circle “Yes” below if you would like for us to conduct your required Clearinghouse Queries. By selecting yes, Motor Carrier agrees to comply with Clearinghouse requirements for conducting Queries and will complete all necessary items for KT Health to conduct Queries on your behalf. Yes No **KTHC Fee per Query is $17, Driver registration performed at KT Health is $27, Driver Registration performed via phone is $37. Clearinghouse Queries are required for all new hires (pre-employment), and all Active Drivers 1x annually. KTHC is not responsible for fees charged to motor carrier by FMCSA for clearinghouse activities. By selecting yes, motor carrier agrees to comply with FMCSA Clearinghouse requirements and will complete all necessary items for KT Health to conduct Queries or report on your behalf.Please select DOT regulating agency for your company* FMCSA PHMSA Please list up to three Designated Employee Representatives that we can discuss drug screen results with:Designated Employee Representative ***This agreement expires December 31, 2025 and will be automatically renewed indefinitely for additional 12 month terms beginning January 1st of the following term year(s). The $135 Consortium annual fee is due on December 1st each year and will be charged to credit card on file unless terminated in writing with a minimum of 30-days notice prior to end of current contract year. All clearinghouse Query fees will be charged as incurred. ***KTHC reserves the right to terminate this agreement with no notice with motor carriers that do not actively participate or Meet requirements of our DOT consortium. Signing below indicates your agreement and understanding.Signature/Name of Motor Carrier RepresentativeTotal $0.00 NameThis field is for validation purposes and should be left unchanged. Δ
2032 East Kearney Suite 108
Springfield, MO 65803
M-F 8am to 4pm
