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:_______________________________________ American LegalNet, Inc. www.FormsWorkFlow.com ***************************************************************** 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: _____________________ American LegalNet, Inc. www.FormsWorkFlow.com