DWI Resource Center, Inc.


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Alcohol & Drug-Free Workplace Program Enrollment Form

Thank you for your interest in the DWI Drug-Free Workplace Program. Remember, enrollment is free to all City of Albuquerque businesses! To enroll in the program and take the first step to an alcohol and drug-free work environment, just fill out the form below and press the submit button. When we have reviewed your form, a member of our staff will contact you by telephone to set up your on-site consultation.


PLEASE NOTE: All fields are mandatory unless otherwise indicated.

CONTACT INFORMATION
 
Primary Contact:
Title:
Business Name:
Type of Business:
Website Address: (optional)
Primary Contact Email:
Address 1:
Address 2: (optional)
City:
State:    Zip:      County:  
Business Phone:   XXX-XXX-XXXX
Business Fax:   XXX-XXX-XXXX     (optional)

COMPANY INFORMATION
 
Total No. of Employees

Does your company currently have: (check all that apply)

     Written alcohol/drug policies
     A safety program
     A substance abuse program
     Pre-employment drug testing
     Post-accident drug testing
     Reasonable Cause/Suspicion drug testing
     Random Drug-Testing
     Alcohol/Drug awareness training
     Safety meetings
     Alcohol/Drugs Detection Training
     DWI-awareness activities
     Company newsletter
     None of the above

PROGRAM INTERESTS

If your company does not currently have an alcohol/drug policy, please check your reasons for establishing a new program: (check all that apply)

     To create a drug-free work environment for my company
     To conduct drug and alcohol testing of my employees
     To qualify for reduction in my workers' compensation
     To educate my employees about the dangers of workplace substance abuse
     To help reduce DWI in New Mexico
     To be in compliance with state or federal requirements
     To advertise my company as a "Drug-Free" company
     To associate my company in the public mind with DWI reduction efforts (cause-related branding)
     Other (please specify):

   

Specify the Alcohol & Drug-Free Workplace Program services in which you have an interest: (check all that apply)

   Policy development and implementation
   Screening employees for prior DWI offenses
   Employee drug awareness training
   Employee assistance programs
   Supervisor drug and alcohol training
   Drug and alcohol testing information
   Parent Training
   Workplace promotional materials (posters, paycheck inserts, etc.)
     Other (please specify):

   


ATTENTION PLEASE!

Please click on PRINT FORM before you submit your form to us. If there is a problem with the results of your form, we will contact you by telephone and ask you to fax the printed page to us. We appreciate your time and assistance!