top of page
A long-exposure night shot from an elevated vantage point, white and red light trails from passing vehicles curving around a wooded hill below, a faint town glow visible in the distance, and a deep royal blue sky with scattered bright stars above a misty horizon, representing the federally governed SAP evaluation process and the path forward available through Availia TeleHelp PLLC in Spokane and Washington State.

SAP Registration Form

Complete before your DOT SAP evaluation. Provides Availia with the information needed

to begin the SAP process including employer, incident, & Designated Employer Representative (DER) details.

Please Note:

Complete this form before or at the time of your initial SAP appointment.

​

You will need your employer's information, your Designated Employer Representative's contact details, and the date and nature of your DOT violation.

​

If you do not have all of this information available,

contact your employer or DER before completing this form.

 

Incomplete submissions may delay the scheduling of your evaluation.

Availia Client Information (SAP Client):

Date of Birth
Month
Day
Year

Employer & Incident Information:

Date of Incident
Month
Day
Year

Modal Agency

DOT Modal Agency
FAA
FMCSA
FRA
FTA
PHMSA
USCG

Designated Employer Representative

Consortium or TPA?
No
Yes (If Yes, please list the C/TPA Name & Phone Number):

Client Acknowledgment

Availia TeleHelp PLLC and signee agree that any digital signature may serve the full legal effect and function of a handwritten signature.

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.
bottom of page