Form CL DIR "Application for Licensure as Clinical Laboratory Director" - Hawaii

What Is Form CL DIR?

This is a legal form that was released by the Hawaii Department of Health - a government authority operating within Hawaii. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on March 1, 2009;
  • The latest edition provided by the Hawaii Department of Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form CL DIR by clicking the link below or browse more documents and templates provided by the Hawaii Department of Health.

ADVERTISEMENT
ADVERTISEMENT

Download Form CL DIR "Application for Licensure as Clinical Laboratory Director" - Hawaii

514 times
Rate (4.4 / 5) 26 votes
DO NOT WRITE IN SHADED SECTION
Date:
Date:
APPROVED
DISAPPROVED
$_____
TYPE OF FEE PAID:
APPLICATION $25
LICENSE
STATE OF HAWAII
Check No./Date:
DEPARTMENT OF HEALTH
STATE LABORATORIES DIVISION
Receipt No./Date:
2725 WAIMANO HOME ROAD
PEARL CITY, HAWAII 96782
NOTES:
APPLICATION FOR LICENSURE AS
Clinical Laboratory Director
LICENSE
DATE LOGGED
NO. ISSUED
DATE MAILED
DATABASE
B/B
USE TYPEWRITER OR PRINT CLEARLY
FULL NAME:
Last
First
Middle
XXX - XX -
SSN LAST FOUR #'s:
DATE OF BIRTH:
HOME ADDRESS:
TELEPHONE-RESIDENCE:
(
)
-BUSINESS:
(
)
City
State
Zip Code
E-MAIL:
EMPLOYER’S NAME AND ADDRESS:
YEARS
EDUCATION
NAME & LOCATION
MAJOR OR MINOR
DEGREE/DATE RCVD.
ATTENDED
High School
Training or
Technical School
College or
University
All professional experience or training during the past 5 or more years
Attach a description of duties performed
Date of
Employment
Employer’s Name
Address
Position Title
From - To
CL DIR (revised 3/2009)
DO NOT WRITE IN SHADED SECTION
Date:
Date:
APPROVED
DISAPPROVED
$_____
TYPE OF FEE PAID:
APPLICATION $25
LICENSE
STATE OF HAWAII
Check No./Date:
DEPARTMENT OF HEALTH
STATE LABORATORIES DIVISION
Receipt No./Date:
2725 WAIMANO HOME ROAD
PEARL CITY, HAWAII 96782
NOTES:
APPLICATION FOR LICENSURE AS
Clinical Laboratory Director
LICENSE
DATE LOGGED
NO. ISSUED
DATE MAILED
DATABASE
B/B
USE TYPEWRITER OR PRINT CLEARLY
FULL NAME:
Last
First
Middle
XXX - XX -
SSN LAST FOUR #'s:
DATE OF BIRTH:
HOME ADDRESS:
TELEPHONE-RESIDENCE:
(
)
-BUSINESS:
(
)
City
State
Zip Code
E-MAIL:
EMPLOYER’S NAME AND ADDRESS:
YEARS
EDUCATION
NAME & LOCATION
MAJOR OR MINOR
DEGREE/DATE RCVD.
ATTENDED
High School
Training or
Technical School
College or
University
All professional experience or training during the past 5 or more years
Attach a description of duties performed
Date of
Employment
Employer’s Name
Address
Position Title
From - To
CL DIR (revised 3/2009)
Other current and valid state licenses
Name of State
License Category
License No.
Date Issued
Professional Certification
Name of Agency
Category
Registry No.
Date Issued
1.
Has your license in any state or country ever been revoked, suspended, or otherwise subject to disciplinary action?
If “yes” specify state where action took
place.
2.
Are you presently being investigated or is any disciplinary action presently pending against you relating to your
performance as a clinical laboratory professional?
If “yes”, please explain:
I hereby certify that the foregoing statements are true to the best of my knowledge. Also, I understand that
any expenses incurred for taking the examination or for evaluation of my credentials, will be my
responsibility and are not part of the license fee.
Signature (in ink)
Date
Send this completed application and required documents to:
Hawaii State Laboratories Division
Clinical Laboratory Personnel Licensing
2725 Waimano Home Road
Pearl City, HI 96782
If you have any questions or concerns, please call (808) 453-6653.
CL DIR (revised 3/2009)
Page of 2