Certifying Scientists for Negative Tests NAME FLORIDA CLINICAL FLORIDA FLORIDA LICENSURE TOXICOLOGY LABORATORY LICENSE LICENSE LEVEL SPECIALTY(S) EXPERIENCE NUMBER (IF REQUIRED) (IF REQUIRED) (YEARS) (REQUIRED ONLY IF LABORATORY IS LOCATED IN THE STATE OF FLORIDA) Person(s) Responsible for the day-to-day Supervision of Analysts NAME FLORIDA CLINICAL FLORIDA FLORIDA LICENSURE TOXICOLOGY LABORATORY LICENSE LICENSE LEVEL SPECIALTY(S) EXPERIENCE NUMBER (IF REQUIRED) (IF REQUIRED) (YEARS) (REQUIRED ONLY IF LABORATORY IS LOCATED IN THE STATE OF FLORIDA) Technical Personnel Performing Toxicology Testing NAME FLORIDA CLINICAL FLORIDA FLORIDA LICENSURE TOXICOLOGY LABORATORY LICENSE LICENSE LEVEL SPECIALTY(S) EXPERIENCE NUMBER (IF REQUIRED) (IF REQUIRED) (YEARS) (REQUIRED ONLY IF LABORATORY IS LOCATED IN THE STATE OF FLORIDA) 6. Required Disclosure The following disclosures are required: Pursuant to section 408.809, F.S., the applicant shall submit to the Agency a description and explanation of any convictions of offenses prohibited by sections 435.04 and 408.809(4), F.S., for each controlling interest. Has the applicant or any individual listed in sections 3 and 4 of this application been convicted of any level 2 offense pursuant to section 408.809, F.S.? YES NO
Certifying Scientists for Negative Tests NAME FLORIDA CLINICAL LABORATORY LICENSE NUMBER (REQUIRED ONLY IF LABORATORY IS LOCATED IN THE STATE OF FLORIDA) FLORIDA LICENSE LEVEL (IF REQUIRED) FLORIDA LICENSURE SPECIALTY(S) (IF REQUIRED) TOXICOLOGY EXPERIENCE (YEARS) Person(s) Responsible for the day-to-day Supervision of Analysts NAME FLORIDA CLINICAL LABORATORY LICENSE NUMBER (REQUIRED ONLY IF LABORATORY IS LOCATED IN THE STATE OF FLORIDA) FLORIDA LICENSE LEVEL (IF REQUIRED) FLORIDA LICENSURE SPECIALTY(S) (IF REQUIRED) TOXICOLOGY EXPERIENCE (YEARS) Technical Personnel Performing Toxicology Testing NAME FLORIDA CLINICAL LABORATORY LICENSE NUMBER (REQUIRED ONLY IF LABORATORY IS LOCATED IN THE STATE OF FLORIDA) FLORIDA LICENSE LEVEL (IF REQUIRED) FLORIDA LICENSURE SPECIALTY(S) (IF REQUIRED) TOXICOLOGY EXPERIENCE (YEARS) 6. Required Disclosure The following disclosures are required: Pursuant to section 408.809, F.S., the applicant shall submit to the Agency a description and explanation of any convictions of offenses prohibited by sections 435.04 and 408.809(4), F.S., for each controlling interest. Has the applicant or any individual listed in sections 3 and 4 of this application been convicted of any level 2 offense pursuant to section 408.809, F.S.? YES NO
HealthCareLicensingApplication_ForensicTox_Laboratory_AHCAForm3170_5001_July2018.docx