"Application for Re-certification of Drug-Free Workplace Premium Credit Program" - Alabama

Application for Re-certification of Drug-Free Workplace Premium Credit Program is a legal document that was released by the Alabama Department of Labor - a government authority operating within Alabama.

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APPLICATION FOR RE-CERTIFICATION OF
DRUG-FREE WORKPLACE PREMIUM CREDIT PROGRAM
DIRECTIONS: After reading and understanding the rules and guidelines, please complete the following
application and return only this application and a $25.00 check for the re-certification fee to the following
address. Keep the documentation of your compliance in your files for review by your insurer or the
Department of Labor, Workers' Compensation Division.
Alabama Department of Labor
Finance Division, Room 228
Attn: Central Cashier
649 Monroe Street
Montgomery, Alabama 36131
Drug-Free Workplace Coordinator:______________________________________________
Company:__________________________________________________________________
Address:___________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
Email Address: _________________________________
Phone number: (
)
Number of Employees: _________
This is our company's (Please check one.)
__________second year, __________third year,
_________fourth year of application for re-certification as a drug-free workplace.
*****************************************************************
TO BE COMPLETED BY THE DEPARTMENT OF LABOR, WORKERS' COMPENSATION
DIVISION.
Date of Re-certification:__________________________
Approved By:_______________________________________
APPLICATION FOR RE-CERTIFICATION OF
DRUG-FREE WORKPLACE PREMIUM CREDIT PROGRAM
DIRECTIONS: After reading and understanding the rules and guidelines, please complete the following
application and return only this application and a $25.00 check for the re-certification fee to the following
address. Keep the documentation of your compliance in your files for review by your insurer or the
Department of Labor, Workers' Compensation Division.
Alabama Department of Labor
Finance Division, Room 228
Attn: Central Cashier
649 Monroe Street
Montgomery, Alabama 36131
Drug-Free Workplace Coordinator:______________________________________________
Company:__________________________________________________________________
Address:___________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
Email Address: _________________________________
Phone number: (
)
Number of Employees: _________
This is our company's (Please check one.)
__________second year, __________third year,
_________fourth year of application for re-certification as a drug-free workplace.
*****************************************************************
TO BE COMPLETED BY THE DEPARTMENT OF LABOR, WORKERS' COMPENSATION
DIVISION.
Date of Re-certification:__________________________
Approved By:_______________________________________
*****************************************************************
I, ___________________________________________________________, in my capacity
(Name)
as ___________________________________________________________ , attest that the
(Title)
Drug-Free Workplace Policy for _______________________________________________
(Company Name)
has not changed since the last certification by the Department of Labor, Workers' Compensation Division, on
________________________________.
(Date of Previous Certification)
OR
I, ___________________________________________________________, in my capacity
(Name)
as ___________________________________________________________ , attest that the
(Title)
Drug-Free Workplace Policy for _______________________________________________
(Company Name)
has changed since the last certification by the Department of Labor, Workers' Compensation Division, on
________________________________. A copy of the new/revised
(Date of Previous Certification)
policy is attached for review by the Workers' Compensation Division.
Notarization of Certified Drug-Free Workplace Program
______________________________ ______________________________
Employer Name
Officer/Owner Signature*
______________________________ ______________________________
Date
Title of Officer/Owner
*
Application must be signed by an officer or owner.
Sworn to and subscribed before me this __________ day of __________________ 20_____.
_____________________________________________
Notary Public
My Commission Expires: _____________________
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