New Jersey Department of Health

Clinical Laboratory Improvement Services

PO Box 361

Trenton, NJ 08625-0361	APPLICATION FOR A CLINICAL LABORATORY LICENSE

(COLLECTION STATION ONLY-$200)

Type of Application

Initial Renewal
FOR STATE USE ONLY:	Date Received	Received By	Approved
Check Number	Amount	Check Date

Name of Collection Station

Name of Parent Lab

Street Address

Street Address

City, State, Zip Code

City, State, Zip Code

CLIS ID Number

Normal Hours of Operation of Collection Station

[Indicate specific hours EACH day]:
Name of Contact Person

Monday
Tuesday
Telephone Number

( )	Wednesday
Thursday
Fax Number

( )	Friday
Saturday
E-Mail Address

Sunday
PHYSICAL PLANT
1.	Location of Collection Station
Store Residence Mobile Physician Office Professional Building
Other, specify:
2.	Are quarters shared with any other enterprise?	Yes No
If yes, specify:
3.	Does collection station have private entrance and exit?	Yes No
4.	Do you have a lease/rental agreement	Yes 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?	Yes No
6.	Is there a sign on the exterior of the building and is the laboratory’s collection station listed on the building directory?	Yes No
CERTIFICATION
We 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 Director	Date
Signature of Owner	Date
Signature of Owner	Date
Signature of Owner	Date

APPLICATION FOR A CLINICAL LABORATORY LICENSE, Continued

CL-18

JUL 12

CL-18, Application for Clinical Lab License, Collection Station Only

cl-18, laboratory, application for clinical laboratory license, clinical laboratory license application, collection station

EWhite

2008-06-26

NJDOH