LABORATORY PERSONNEL QUALIFICATION APPRAISAL and ...

1 CLTL - 103 LABORATORY PERSONNEL QUALIFICATION APPRAISALand APPLICATION FOR LICENSUREWEST VIRGINIA DEPARTMENT OF HEALTH AND HUMAN RESOURCESOFFICE OF LABORATORY SERVICES167 11th AvenueSouth Charleston, West Virginia 25303 Name Social Security Number - - LABORATORY CLIA Certificate No. GENERAL in ink or type all information. Avoid abbreviations, if possible. Do not abbreviate name ofcity or all items that apply to you. If more space is required, specific pages may be check or money order, ($ ) to the application payable to State of West VirginiaDHHR Lab. Do not send sure the application is signed in places designated by applicant and LABORATORY director, ifcurrently which are not completed or applications submitted with an incorrect fee will bereturned and will not be Office of LABORATORY Services, at the above address, of any change of address or change ofname (by marriage or divorce), or any change of work performing only waived tests as defined in the Clinical LaboratoryImprovement Amendments (CLIA) of 1988 are not required to be licensed and do notneed to complete this providing diagnostic testing within the scope of his/h

1 cltl - 103 laboratory personnel qualification appraisal and application for licensure west virginia department of health and human resources office of laboratory services

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