Application-Clinical Laboratory Registration
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Application-Clinical Laboratory Registration Form. This is a California form and can be use in Department Of Health And Human Services Statewide.
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Tags: Application-Clinical Laboratory Registration, LAB 155, California Statewide, Department Of Health And Human Services
AgencyAPPLICATION FOR CLINICAL LABORATORY REGISTRATION Instructions:002003002003002003 American LegalNet, Inc. www.FormsWorkFlow.com 7.Laboratory Director(s) (M.D., D.O.)Hour Per Week On Site Name Address (number, street) City State Zip Code Name Address (number, street) City State Zip Code Name Address (number, street) City State Zip Code Name Address (number, street) City State Zip Code Name Address (number, street) City State Zip Code Name Address (number, street) City State Zip Code This statement must be signed by the owner or a person legally authorized to bind the owner and the laboratory director. 002I declare that the foregoing statements are true and correct to the best of my knowledge and 002belief. 002Laboratory Director Signature Type or Print Name Title Date Owner Signature Type or Print Name Title Date Agency American LegalNet, Inc. www.FormsWorkFlow.com
