Nevada > Statewide > Health Division > Bureau Of Licensure And Certification
Licensed Laboratory Request For Off-Site Testing Application - Nevada
| Licensed Laboratory Request For Off-Site Testing Application Form. This is a Nevada form and can be used in Bureau Of Licensure And Certification Health Division Statewide . |
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LICENSED LABORATORY REQUEST FOR OFF-SITE TESTING APPLICATION Page 1 of 1 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 This application must be accompanied by a check for $300.00 per event made payable to the Nevada State Treasurer. 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 Licensed Laboratory Name and License # Phone Number (starting with the area code) Address City County State Zip Code Name of Licensed Laboratory Director Date/Time: Location Address City County Test(s) to be performed Name of general supervisor on site Name of technologist(s)/technician(s)/assistant(s) performing offsite testing (attach list if necessary) OFF-SITE TESTING INFORMATION 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: State of: Subscribed and sworn before me this: Date: County of: Day of: For Official Use Only: 8/25/2011 American LegalNet, Inc. www.FormsWorkFlow.com
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