Licensed Laboratory Request For Off-Site Testing Application
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Licensed Laboratory Request For Off-Site Testing Application Form. This is a Nevada form and can be use in Health Division Statewide.
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Tags: Licensed Laboratory Request For Off-Site Testing Application, Nevada Statewide, Health Division
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
LICENSED LABORATORY
REQUEST FOR OFF-SITE
TESTING APPLICATION
Page 1 of 1
This application must be accompanied by a check for $300.00 per event made payable to the Nevada State Health Division. Under
Nevada Administrative Code (NAC) 652.488 the fee is nonrefundable. Insufficient funds charge: $25.00 per NAC 353C.400.
Regulations may be viewed at http://leg.state.nv.us.
REQUEST FOR LICENSING OF HEALTH FAIRS AND OTHER HEALTH RELATED SPECIAL EVENTS MUST BE
RECEIVED BY THIS OFFICE NO LATER THAN (10) CALENDAR DAYS PRIOR TO INTIAL DATE OF TESTING.
The fee for licensure is $300.00 per application. One application per event location.
LABORATORY INFORMATION
OFF-SITE TESTING INFORMATION
Licensed Laboratory Name and License #
Date/Time:
Phone Number (starting with the area code)
Location
Address
Address
City
City
County
County
State
Test(s) to be performed
Zip Code
Name of general supervisor on site
Name of Licensed Laboratory Director
Name of technologist(s)/technician(s)/assistant(s) performing offsite testing (attach list if necessary)
MUST BE NOTARIZED BELOW
Lab Physician/Director’s Signature
Please PRINT and SIGN Name
Must be an ORIGINAL: photocopies or signature stamps are not
acceptable.
Name and Signature of Notary:
Date:
State of:
County of:
Subscribed and sworn before me this:
Day of:
For Official Use Only:
11/30/2010
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