1/2009 AADT-American Alliance Drug Testing 326 N. Euclid Ave Upland, CA 91786 (800) 820-9314 fax (909) 608-2058 CSAT FORM 500
AADT CONSENT TO RELEASE ACTIVITY STATUS
I, (PRINT NAME) _____________________________________, as the undersigned Independent Contractor Owner-Operator (Owner-
Operator), expressly consent to share with the third party Overlying Carrier/Broker (Broker) listed below a notification of my activity or
inactivity in the American Alliance Drug Testing (AADT), a subsidiary of California Drug & Alcohol Testing Alliance (C-DATA), controlled
substance and alcohol testing program, of which I am a participant. I expressly direct AADT to notify Broker of my activity status in
AADT’s program, unless Broker should decline further receipt of my activity status at any time.
I understand that the only information that will be supplied to Broker by AADT should I become inactive is a notification of my inactivity
in the AADT controlled substance and alcohol testing program. No specific reason will be given to Broker for my inactivity in AADT’s
program, only the following explanation will be provided:
Please be advised that the Independent Contractor Owner-Operator (Owner-Operator) listed below is no longer active in
the American Alliance Drug Testing (AADT) controlled substance and alcohol testing program. Please note that there are
many reasons as to why the Owner-Operator may have become inactive with AADT. Reasons include, but are not limited
to, non-payment for services rendered, incorrect company/driver information, a positive controlled substance or breath
alcohol test result, or failure to comply with the U.S. Department of Transportation (DOT) requirements of a return to duty
process including an Employee Assistance Program. Additionally, the Owner-Operator may have also requested to be
inactivated for reasons including, but not limited to, illness or disability, temporarily out of service, permanently ceased
operations, or elected another consortium.
This authorization is valid until withdrawn by me, the Owner-Operator, and until AADT and the listed Broker have received a
written notice of revocation from me. AADT will notify me should Broker decline to further receive my activity status in AADT’s
program.
Independent Contractor Owner-Operator’s Name: ________________________________________________________________
Company Name: ________________________________________________________________
Address: ________________________________________________________________
City/State/Zip: ________________________________________________________________
Contact Phone Number: ________________________________________________________________
CA Number: ________________________ AADT I.D. Number: _______________________
Commercial Driver License Number (CDL): ________________________ Birth Date (optional) _______________________
Signature: ________________________________________________________________
Date: ________________________________________________________________
Overlying Carrier/Broker D&A Supervisor: ________________________________________________________________
Company Name: ________________________________________________________________
Address: ________________________________________________________________
City/State/Zip: ________________________________________________________________
Contact Phone Number: ________________________________________________________________
Secured Fax Number: ________________________________________________________________
CA Number: ____________________ AADT I.D. Number (if applicable): ________________
Signature: ________________________________________________________________
Date: ________________________________________________________________
AADT Representative & Title: ________________________________________________________________
Signature: ________________________________________________________________
Date: ________________________________________________________________
This Agreement contains the entire agreement of the parties with respect to the subject matter of this Agreement, and supersedes all
prior negotiations, agreements and understandings with respect thereto.
