ࡱ> OQNq  bjbjt+t+ 0NAA- J]NNNNNNNbbbb8DtbntSL(`bbbbbb$QN NNn   .NN`bbNNNN`  @NN`R `dbb"XNew Jersey Department of Health Clinical Laboratory Improvement Services PO Box 361 Trenton, NJ 08625-0361APPLICATION FOR A CLINICAL LABORATORY LICENSE (COLLECTION STATION ONLY-$200) Type of Application  FORMCHECKBOX  Initial  FORMCHECKBOX  RenewalFOR STATE USE ONLY:Date ReceivedReceived By FORMCHECKBOX  ApprovedCheck NumberAmountCheck Date Name of Collection Station  FORMTEXT      Name of Parent Lab  FORMTEXT      Street Address  FORMTEXT      Street Address  FORMTEXT      City, State, Zip Code  FORMTEXT      City, State, Zip Code  FORMTEXT      CLIS ID Number  FORMTEXT      Normal Hours of Operation of Collection Station [Indicate specific hours EACH day]:Name of Contact Person  FORMTEXT      Monday FORMTEXT      Tuesday FORMTEXT      Telephone Number (  FORMTEXT       )  FORMTEXT      Wednesday FORMTEXT      Thursday FORMTEXT      Fax Number (  FORMTEXT       )  FORMTEXT      Friday FORMTEXT      Saturday FORMTEXT      E-Mail Address  FORMTEXT      Sunday FORMTEXT      PHYSICAL PLANT1. Location of Collection Station  FORMCHECKBOX  Store  FORMCHECKBOX  Residence  FORMCHECKBOX  Mobile  FORMCHECKBOX  Physician Office  FORMCHECKBOX  Professional Building  FORMCHECKBOX  Other, specify:  FORMTEXT      2. Are quarters shared with any other enterprise?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, specify:  FORMTEXT      3. Does collection station have private entrance and exit?  FORMCHECKBOX  Yes  FORMCHECKBOX  No4. Do you have a lease/rental agreement  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, please enclose a copy of the lease/rental agreement, and a scale floor plan of the Collection Station that illustrates the relationship between the Collection Station and any other health services purveyor(s).5. Is the Collection Station open to the general public?  FORMCHECKBOX  Yes  FORMCHECKBOX  No6. Is there a sign on the exterior of the building and is the laboratorys collection station listed on the building directory?  FORMCHECKBOX  Yes  FORMCHECKBOX  NoCERTIFICATIONWe the undersigned certify that all the information given on this application and on the accompanying attachments is true, correct and complete as of this date and that notification, by certified mail, of any change(s) will be made within 14 days of such change(s). We further certify that testing will not be performed until all applicable State and Federal certificates, licenses and required approvals have been obtained.Signature of DirectorDateSignature of OwnerDateSignature of OwnerDateSignature of OwnerDate APPLICATION FOR A CLINICAL LABORATORY LICENSE, Continued CL-18 JUL 12 k !;<JKLVWyz{  46JԸԢ敍}n敍j5CJOJQJUmHj^5CJOJQJU5CJOJQJj5CJOJQJUjCJOJQJU5CJOJQJjtCJOJQJUjCJOJQJU CJOJQJjCJOJQJU CJOJQJ CJOJQJOJQJ 5OJQJ) ITk  !/;V $$ ! $ !$ ! !3$$THh40)$ $$  @@@ ITk  !/;JKVWXYZgnyz{ 4NX\^|2<@l<      ( B L P R T v       [VWXYZgnyz{WQ !A$$TH44L H(") $ !_$$TH44ֈ H(")`` {4\^|@l<T$ !3$$TH40)   $ ! 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