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Clinical Laboratory License Application - Department of Health (New Jersey) Mobile App

This is an Application for a Clinical Laboratory License from the New Jersey Department of Health. It works just like the paper form, complete with all capture fields such as name of collection station, name of parent lab, hours of operation, and more.

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Take a peek inside the Clinical Laboratory License Application - Department of Health (New Jersey) Mobile App

Included Features

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Included Fields

Customize to add, remove, or edit any of the fields below.

  • Ico dropdown

    Type of Application

  • Ico textbox

    Name of Collection Station

  • Ico textbox

    Name of Parent Lab

  • Ico multiline

    Address

  • Ico textbox

    CLIS ID Number

  • Ico textbox

    Name of Contact Person

  • Ico textbox

    Telephone Number

  • Ico textbox

    Fax Number

  • Ico textbox

    E-Mail Address

  • Ico statictext

    Normal Hours of Operation of Collection Station [Indicate specific hours EACH day]:

  • Ico integer

    Monday

  • Ico integer

    Tuesday

  • Ico integer

    Wednesday

  • Ico integer

    Thursday

  • Ico integer

    Friday

  • Ico integer

    Saturday

  • Ico integer

    Sunday

  • Ico dropdown

    1. Location of Collection Station

  • Ico dropdown

    Are quarters shared with any other enterprise?

  • Ico multiline

    If yes, specify:

  • Ico dropdown

    Does collection station have private entrance and exit?

  • Ico dropdown

    4. Do you have a lease/rental agreement

  • Ico statictext

    If yes, please enclose a copy of the lease/rental agreement, and a scale floor plan of the Collec...

  • Ico dropdown

    Is the Collection Station open to the general public?

  • Ico dropdown

    Is there a sign on the exterior of the building and is the laboratory’s collection station liste...

  • Ico checkbox

    We the undersigned certify that all the information given on this application and on the accompan...

  • Ico signature

    Signature of Director

  • Ico signature

    Signature of Owner

  • ...and More!

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