DATIA Membership Renewal

If your membership has been expired for more than FOUR months, please use
the New Member Application to pay prorated dues.


Part 1: Company Information

*Please enter information exactly as it should be listed in our online directory.*
Company Name
Member Number	(if you have it from your renewal notice)
Primary Contact Name
Primary Contact's Email
Address
City
State/Province
Country
Zip
Phone
Fax
Website

More Info (optional)
Number of employees at this facility
Total # of employees at all facilities
Number of drug tests performed each year
Number of employers for whom you perform drug and/or alcohol testing
"The information provided above will be used for DATIA statistical purposes only. It will not be provided to any other parties, or used in your company's Searchable Internet Industry Directory listing."

Note: Fields in red are required values

Part 2: Membership Categories

Below, please find an outline of the benefits associated with each membership level. While you are to join at the minimum level based on the size of your organization, feel free to join at a higher level to take advantage of increased benefits.
Member Benefits Overview
Receive quarterly DATIA focus Magazine Receive bi-weekly DATIA eNews Receive full access to information on datia.org Are listed on the Searchable Internet Drug & Alcohol Testing Industry Directory and Buyers' Guide Receive Washington Representation and regulatory alerts Have full voting privileges on association matters Have the opportunity to be elected to serve on the association's Board of Directors Can attend DATIA networking events and legislative and regulatory briefings at member rates Receive discounts on publications, annual conferences and training sessions

Membership Categories (please choose one)

Regular (1-5 employees) ($295) - All benefits in above overview plus:

Searchable Internet Drug & Alcohol Testing Industry Directory and Buyers' Guide Listing in a total of three categories

Corporate (6+ employees) ($595) - All benefits in above overview plus:

Searchable Internet Drug & Alcohol Testing Industry Directory and Buyers' Guide Listing in a total of eight categories for up to five company locations
Ability to have up to five company representatives individually receive DATIA focus and other pertinent mailings
Opportunity to purchase a one-time use set of DATIA Membership Mailing Labels for use in marketing

Sustaining ($2300) - All benefits in above overview plus:

Searchable Internet Drug & Alcohol Testing Industry Directory and Buyers' Guide Listing in an unlimited number of categories for an unlimited number of company-owned and operated sites
Free bolding and free 50 word description in the online directory
Ability to have up to 10 company representatives individually receive DATIA focus and other pertinent mailings
Listing of company on DATIA letterhead
Prominent listing on the DATIA website with a link to company's website
One complimentary set of one-time use DATIA Membership Mailing Labels for use in marketing, and the opportunity to purchase additional sets
20% discount on conference sponsorship with preferred booth location
One complimentary registration to the DATIA Annual Conference

Part 3: Promotional Categories for Industry Directory

Do Not List in Online Directory Please check the categories under which you would like your company's listing to appear. Regular Membership (1-5 employees) includes three (3) complimentary categories Corporate Membership (6+ employees) includes eight (8) complimentary categories Sustaining Membership includes unlimited complimentary category listings Additional category listings can be purchased for $15 per category.
Employer
I am an EMPLOYER/COMPANY running an in-house drug and alcohol testing program for our safety-sensitive and/or other employees. Our company does not provide drug and alcohol testing services to clients.
Service Categories
Alternative Specimen Testing	Consortium/TPA
Collection Services	DOT Physicals	Employee Assistance Programs
Alcohol Testing – BAT	Medical Review Officer	Freelance Specimen Collection
Supervisor/Employee Training	Consulting
Mobile Collections	Non-mandated Testing	On-Site Testing
Drug-Free Policy Development	Substance Abuse Counseling/Treatment	Substance Abuse Professional
Student Drug Testing	24 Hour Availability	QA Services
Background Screening	DNA Testing	Laboratory
Wellness Programs	Franchise & Business Opportunities
Supplier Categories
Urine Specimen Collection Supplies	Hair Drug Testing Supplies	Oral Fluid Drug Testing Supplies
Drug Testing Laboratory - Urine	Drug Testing Laboratory - Oral Fluids	Drug Testing Laboratory - Hair
Breath Alcohol Testing Instruments/Supplies	Oral Fluid Alcohol Testing Instruments/Supplies	Point of Collection Drug Testing Kits
Drug and Alcohol Testing Software	Training Supplies
Agency and Modes Tested
FAA FMCSA FRA FTA PHMSA USCG DOD DOE NASA NRC
Promotional 50 Word Listing
Increase the effectiveness of your listing by including a 50-word description of your company's products and/or services. The description will be included in all categories under which your company appears. This feature is available for $50. This description is complimentary for Sustaining Members. (No descriptions beyond 50 words will be accepted)

Bolding
YES! Please print my listing in Bold Print.

If your membership has been expired for more than FOUR months, please use the New Member Application to pay prorated dues.

Part 4: Dues

	Membership Dues	Category Listings*	50 Word Description	Bold Print Listing	Total
	Regular (1-5 employees) $295	=
	Corporate (6+ employees) $595	=
	Sustaining $2300	no charge	no charge	no charge
*Optional Additional DATIA focus* Subscriptions**
	Annual Subscription - $48	=

	*(regular includes 3 categories, corporate 8, sustaining unlimited)

Part 5: Optional Donations

How should your donation be recognized?

Company Name

Individual Name This donation has been made on behalf of:

Name:
Company:
Address:
City:
State:
Zip:
Phone:
Email:

Note: DATIA will contact this person to inform them of your donation on their behalf.

Please accept my donation to the Diana Bauske Educational Scholarship Fund

Please accept my donation to the Marijuana Outreach Education Fund

Part 6: Payment Information
Promo Code: Enter your promo code here. Discounts based on your promo code will be applied before payment is processed. TOTAL
Payment Type:	MC VISA AMEX
Cardholder's Name	Card #
Exp. Date
Refund/Credit Policy: DATIA membership dues and associate fees are non-refundable per DATIA’s By-Laws. Membership may be upgraded at any time for a prorated fee, based on the date of the upgrade and the current membership status. Please submit upgrade requests in writing to info@datia.org.
This online registration form is secured utilizing the highest level of encryption security possible. This means you can rest assured that communications (e.g. credit card numbers) between your browser and this site's web servers are private and secure.
This is a secure order form but if you prefer to print this out our Fax is: (202) 315-3579 For Check payments please print this out and send to: DATIA • 1325 G Street, NW, Suite 500#5001 Washington, DC 20005

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