DOH 505-039 July 2024 Page 2 of 3
Phone and Fax Numbers: Enter the lab’s phone and fax number.
Mailing Address: Enter the lab’s mailing address, if dierent than physical address.
F Section 2. Facility Specic Information:
Site Type: Please check one applicable site type.
Hours of Testing: List the days and hours of testing for this site.
Additional locations under this license: Attach a list of names, addresses and phone
numbers for additional locations, if applicable, and test(s) performed at each site.
F Section 3. Key Individuals:
Lab Director: Enter the lab director’s:
1. First name, last name, and Washington State professional license number, if applicable.
2. Email address.
3. If the director of this laboratory serves as the director for any separately licensed
laboratory, provide the name and CLIA number of the laboratory. Include laboratories
licensed in other states.
Lab Contact: Enter the lab contact’s:
1. First name, last name, and Washington State professional license number, if applicable.
2. Email address.
The lab contact will receive all information that we mail to your medical test site.
F Section 4. Additional Information—Waived Tests:
Fill in the test system and test manufacturer in the provided table for each
test your lab performs. Please verify the waived status of your test system at
https://www.accessdata.fda.gov.
If you perform any non-waived tests, do not complete this application. See the MTS
website to help you determine your correct license category or email the MTS Program at
F Section 5. Other Licensure, Certication, or Registration Information:
Legal Owner: List the names, titles, addresses, and phone numbers of the corporate
ocers, LLC members or manager, partners, etc. Attach additional pages, if necessary.
I n d i c a t e i f y o u w i s h t o r e t a i n t h e C L I A n u m b e r i f s w i t c h i n g t o n e w l i c e n s e t y p e .
Change of Ownership Information: If applicable, list the previous owner name, previous
name of facility, previous MTS license number, eective date of ownership change and
physical address. Indicate if you wish to retain the CLIA number if changing ownership.
F Section 6. Foreign Ownership: Complete if facility is owned fully or partially by foreign
entity.
F Signature:
The legal owner or authorized representative must sign and date the application. Print the
name and title of the legal owner or authorized representative.