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 American LegalNet, Inc. www.FormsWorkFlow.com