LABORATORY DIRECTOR LICENSE APPLICATION Page 1 of 2 NEVADA STATE HEALTH DIVISION Bureau of Health Care Quality and Compliance 727 Fairview Drive, Suite E Carson City, Nevada 89701 Phone: (775) 684-1030 Fax: (775) 684-1075 http://www.health.nv.gov/HCQC_Medical.htm This application must be accompanied by a check for the appropriate amount made payable to the Nevada State Health Division. Under Nevada Administrative Code (NAC) 652.488 the fee is nonrefundable. Failure to submit appropriate documentation within six (6) months of application submission voids the application. Insufficient funds charge: $25.00 per NAC 353C.400. Regulations may be viewed at http://leg.state.nv.us. The fee for licensure is $500.00 and is valid for two years. Indicate which license you are applying for (select only one box): NAC 652.380 (Licensed Laboratory Director) NAC 652.385 (Pulmonary Laboratory Director) NAC 652.395 (Registered Laboratory Director) Name Date of Birth (i.e., 08/12/1956) Maiden/Previous Name (if applicable) Phone Number (starting with the area code) Social Security Number Mailing Address (if different from street address) Street Address City City County County State State Zip Code Zip Code Please indicate the laboratories at which you will function as a laboratory director (may not exceed five): 1 2 3 4 5 Required Documents: 1 2 3 Copy of current physician’s license must be attached Copies of current board certifications must be attached Original sealed transcripts (for PhDs) required Academic Background: College/University City State Degree Obtained Major Month/Year 11/30/2010 American LegalNet, Inc. www.FormsWorkFlow.com LABORATORY DIRECTOR LICENSE APPLICATION Page 2 of 2 Specialty Training: Facility City State Nature of Training Month/Year Laboratory Training and/or Work Experience: Company Name City State Work Title Supervisor’s Name From Month/Year To Month/Year ALL APPLICANTS MUST COMPLETE THIS SECTION Failure to clearly mark one of the choices below will result in denial of the application. Federal Welfare Reform as implemented by the 1997 Legislative Session NRS 652.095 requires that professional and occupational licensing agencies add the following questions regarding child support to all applications for new licenses and renewals. Your license, issued by the Bureau, is subject to this requirement mandated by the Federal Government of all states, including Nevada. MUST CHOOSE ONLY ONE BOX Please mark the appropriate response: I am not subject to a court order for the support of a child. I am subject to a court order for the support of one or more children and I am in compliance with the order, or I am in compliance with a plan approved by the district attorney or other public agency enforcing the order for repayment of the amount owed pursuant to the order. I am subject to a court order for the support of one or more children and I am not in compliance with the order or a plan approved by the district attorney or other public agency enforcing the order for the repayment of the amount owed pursuant to the order. You are required to contact your local District Attorney or the Welfare Division to arrange payment. Provide evidence of compliance and payment with the application. I hereby certify that all the above statements/information are true, correct and complete to the best of my knowledge. Applicant’s Signature: Date: If you fail to answer the questions or sign this form, your license will NOT be issued and the fee will NOT be refunded. For Official Use Only: 11/30/2010 American LegalNet, Inc. www.FormsWorkFlow.com