Form LAB 158 Continuing Education Waiver Request - California

Form LAB158 or the "Continuing Education Waiver Request" is a form issued by the California Department of Public Health.

The form was last revised in July 1, 2007 and is available for digital filing. Download an up-to-date Form LAB158 in PDF-format down below or look it up on the California Department of Public Health Forms website.

ADVERTISEMENT
California Department of Public Health
State of California—Health and Human Services
CONTINUING EDUCATION WAIVER REQUEST
INSTRUCTIONS:
1. Complete this Continuing Education Waiver Request using a typewriter or pen. If completed in pen, legibly print each entry.
2. Submit this waiver request with your license renewal documents when you renew your license. Waiver requests cannot be
accepted or granted at any other time.
3. Submit a physician’s verification if waiver request is for a disability of six months or more during the past year.
4. Supply confirmatory proof of residency of six months or more, outside the USA or outside California if absence was military
related.
5. You must pay all renewal fees including the continuing education administration fee as disclosed on your renewal notice.
6. If a waiver is granted, the status of your license will be renewed as an active license for the coming year.
7. The waiver is valid for this renewal year. If your situation requires a waiver next year, you must submit a new request.
8. MAIL TO: LABORATORY FIELD SERVICES
Office of Continuing Education
850 Marina Bay Parkway, Bldg. P, 1st Floor
Richmond, California 94804-6403
(510) 620-3800
Name
License number
Telephone (day)
Telephone (home)
-
Mailing address (number, street)
E-mail address
City
State
Country
ZIP code
Describe reason for waiver request
COMPLETE THE APPROPRIATE SECTIONS
1. For disability, indicate dates
Physician verification (Physician, please describe disability and why it prevented continuing education completion.)
Physician signature
Date
Physician name (print)
License number
Address (number, street)
City
State
ZIP code
Telephone
2. Dates of absence from USA (send proof)
Country of residence
3. Dates of military service outside California (send proof)
Where stationed
I hereby apply for a Continuing Education Waiver. I certify that the information presented above is true and correct.
Signature of licensee
Date
LAB 158 (7/07)
California Department of Public Health
State of California—Health and Human Services
CONTINUING EDUCATION WAIVER REQUEST
INSTRUCTIONS:
1. Complete this Continuing Education Waiver Request using a typewriter or pen. If completed in pen, legibly print each entry.
2. Submit this waiver request with your license renewal documents when you renew your license. Waiver requests cannot be
accepted or granted at any other time.
3. Submit a physician’s verification if waiver request is for a disability of six months or more during the past year.
4. Supply confirmatory proof of residency of six months or more, outside the USA or outside California if absence was military
related.
5. You must pay all renewal fees including the continuing education administration fee as disclosed on your renewal notice.
6. If a waiver is granted, the status of your license will be renewed as an active license for the coming year.
7. The waiver is valid for this renewal year. If your situation requires a waiver next year, you must submit a new request.
8. MAIL TO: LABORATORY FIELD SERVICES
Office of Continuing Education
850 Marina Bay Parkway, Bldg. P, 1st Floor
Richmond, California 94804-6403
(510) 620-3800
Name
License number
Telephone (day)
Telephone (home)
-
Mailing address (number, street)
E-mail address
City
State
Country
ZIP code
Describe reason for waiver request
COMPLETE THE APPROPRIATE SECTIONS
1. For disability, indicate dates
Physician verification (Physician, please describe disability and why it prevented continuing education completion.)
Physician signature
Date
Physician name (print)
License number
Address (number, street)
City
State
ZIP code
Telephone
2. Dates of absence from USA (send proof)
Country of residence
3. Dates of military service outside California (send proof)
Where stationed
I hereby apply for a Continuing Education Waiver. I certify that the information presented above is true and correct.
Signature of licensee
Date
LAB 158 (7/07)

Download Form LAB 158 Continuing Education Waiver Request - California

1095 times
Rate
4.5(4.5 / 5) 66 votes
ADVERTISEMENT