Initial Screening/Testing Equipment: Confirmation Testing Equipment: 12. Personnel Please provide the information requested below. Attach additional sheets as needed. Administration PERSONAL ADDRESS FLORIDA LICENSE TELEHPONE TITLE NAME E-MAIL NUMBER NUMBER Laboratory Director Financial N/A Officer Certifying Scientists Clinical Laboratory License Number (Required Toxicology Name only if laboratory is located License Licensure Specialty(s) Experience in the State of ) (If required) (If required) (Years) Certifying Scientists for Negative
Initial Screening/Testing Equipment: Confirmation Testing Equipment: 12. Personnel Please provide the information requested below. Attach additional sheets as needed. Administration TITLE NAME TELEHPONE NUMBER E-MAIL PERSONAL ADDRESS FLORIDA LICENSE NUMBER Laboratory Director Financial Officer N/A Certifying Scientists Name Clinical Laboratory License Number (Required only if laboratory is located in the State of ) License (If required) Licensure Specialty(s) (If required) Toxicology Experience (Years) Certifying Scientists for Negative