Limited Testing Registration (Page 8 of 8) in pdf

Limited Testing Registration Page 8

9. CERTIFICATION

I understand that by signing this application form I agree to any investigation made by the Department of Health to verify or

confirm the information I have given or any other investigation made by them in connection with my request for this laboratory

permit. If additional information is requested, I will provide it. Further, I understand that, should this application or my status

be investigated at any time, I agree to cooperate in such an investigation. In signing this application, I hereby certify that the

information I have given the Department of Health is true and correct.

Print Name of Director

Signature of Director

Date

Print Name of Person Completing this Form

Signature of Person Completing this Form

Date

******* FOR AFFILIATED LABORATORIES ONLY *******

(Complete Area Below Only If You Answered Section 4. Management on Page 2 of This Document)

Print Name of Director of Affiliated Laboratory

Signature of Director of Affiliated Laboratory

Date

The $100.00 application fee must be enclosed with your application. Make checks payable to:

New York State Department of Health.

DOH-4081

(04/03)

Limited Testing Registration Page 8