003 003 State of California227Health and Human Services Agency California Dept. of Public Health Laboratory Field Services 850Marina Bay Parkway Bldg. P. Richmond, CA 94804-6403 TISSUE BANK LICENSE - NEW APPLICATION Division 2, Chapter 4.1, California Health and Safety Code INSTRUCTIONS: Please use typewriter or print in ink. Complete this application and Tissue Bank Personnel Report (LAB 169) and return with the required fee to the above address (no fee is required of district, city, county, or State). 1. Name of tissue bank227Is this a fictitious name? Yes No Telephone number ( ) FAX number ( ) Date 2. Address(es)226REQUIRED If more than one street address is used, list all street addresses and describe services provided at each location. (Number, street) City ZIP code Services provided at this location (Number, street) City ZIP code Services provided at this location Mailing address City ZIP code 3. If this application is being filed because of a change of owner, give effective date of change: 4. Check type of ownership Individual Partnership Corporation Unincorporated association Government entity University of California (constitutional corporation) 5. Attach as appropriate, documentation for business license or permit, partnership agreement, articles of incorporation, corporate index transcript, fictitious name (dba) permit, practice management agreement, and lease agreement. (State name of locality where any fictitious name permit is filed.) 6. Exact name of owner a. If an individual owns the tissue bank, give name and address of individual. Name Address b. If partnership or unincorporated association (whether general or limited), give names of all the members of the partnership. Name Name Address Address c.003 If a corporation owns the tissue bank, state the name of the officers, directors, shareholders holding a 5 percent or more interest in the corporation, and any person, partnership, or corporation who or which has the responsibility to manage or conduct the day-to-day operation of the tissue bank. (Use supplementary sheet if necessary.) Name Address Name Address Name Address Name Address Name Address Name Address Name Address CONTINUED LAB 172 (7/07) American LegalNet, Inc. www.FormsWorkFlow.com 003003 003003 7. Director(s) of tissue bank227include director(s222) name(s) and qualifications listed on Tissue Bank Personnel Report (LAB 169). Director Name Address Hours per Week to be Spent in This Facility 8. List type of tissue(s) collected, processed, stored, or distributed by the tissue bank. Living Donors Deceased Donors 9. Attach a copy of all policies and procedures which pertain to the following and include descriptions of any process utilized by the tissue bank: 003(1) to ensure safe collection, preservation, transporation, storage, and handling of tissue acquired or used by the tissue bank; (2) to determine if donors have been tested or assesssed for the transmission of disease through transplantation; or (3) when appropriate, donors have been tested to determine compatibility. 10. Complete the enclosed Tissue Bank Personnel Report (LAB 169), ART Questionnaire (LAB 170) (if applicable), and return with application. This statement to be signed by the owner or person legally authorized to bind the owner. I declare under penalty of perjury that the foregoing statements are true and correct. Signature Signed this day of , in , . (city)003 (state) Print name LAB 172 (7/07) American LegalNet, Inc. www.FormsWorkFlow.com