"Application/Renewal for a Licence to Operate a Medical Laboratory" - Saskatchewan, Canada

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Laboratory Licensing
Medical Services Branch
nd
2
floor - 3475 Albert Street
Regina, Saskatchewan S4S 6X6
Phone: (306) 787-7988
Fax: (306) 798-1124
Email: LabLicensing@health.gov.sk.ca
APPLICATION/RENEWAL FOR A LICENCE TO OPERATE A MEDICAL LABORATORY
All sections of the application form are required to be completed prior to submission to the Ministry
New Application
Date of Application/Renewal:
______/______/______
Renewal
Licence # ______________
MM
DD
YEAR
Laboratory Facility
Name of Facility________________________________________________________
Telephone # ____________________
Street Address _________________________________________________________
Fax # __________________________
City ___________________________Postal Code _______________
Email ________________________________________
___________________________________________________________________
Mailing Address
(if different than above)
City _________________________________________
Postal Code _______________
Type of Licensee
Individual
Corporation
Partnership
Health Authority
Provincial Government
Canadian Blood Services
Hospital
Other (please specify) ______________________________________________________
Licensee Information
Name ________________________________________________________________
Telephone # ____________________
Mailing Address ________________________________________________________
Fax # __________________________
City ___________________________Postal Code _______________
Email ________________________________________
If partnership or corporation - partners or directors:
Name ________________________________________________________________
Title or Position _________________
Mailing Address ________________________________________________________
Telephone # ____________________
City ___________________________Postal Code _______________
Email ________________________________________
Name ________________________________________________________________
Title or Position _________________
Mailing Address ________________________________________________________
Telephone # ____________________
City ___________________________Postal Code _______________
Email ________________________________________
Name ________________________________________________________________
Title or Position _________________
Mailing Address________________________________________________________
Telephone # ____________________
City ___________________________Postal Code _______________
Email ________________________________________
Page 1 of 4
Laboratory Licensing
Medical Services Branch
nd
2
floor - 3475 Albert Street
Regina, Saskatchewan S4S 6X6
Phone: (306) 787-7988
Fax: (306) 798-1124
Email: LabLicensing@health.gov.sk.ca
APPLICATION/RENEWAL FOR A LICENCE TO OPERATE A MEDICAL LABORATORY
All sections of the application form are required to be completed prior to submission to the Ministry
New Application
Date of Application/Renewal:
______/______/______
Renewal
Licence # ______________
MM
DD
YEAR
Laboratory Facility
Name of Facility________________________________________________________
Telephone # ____________________
Street Address _________________________________________________________
Fax # __________________________
City ___________________________Postal Code _______________
Email ________________________________________
___________________________________________________________________
Mailing Address
(if different than above)
City _________________________________________
Postal Code _______________
Type of Licensee
Individual
Corporation
Partnership
Health Authority
Provincial Government
Canadian Blood Services
Hospital
Other (please specify) ______________________________________________________
Licensee Information
Name ________________________________________________________________
Telephone # ____________________
Mailing Address ________________________________________________________
Fax # __________________________
City ___________________________Postal Code _______________
Email ________________________________________
If partnership or corporation - partners or directors:
Name ________________________________________________________________
Title or Position _________________
Mailing Address ________________________________________________________
Telephone # ____________________
City ___________________________Postal Code _______________
Email ________________________________________
Name ________________________________________________________________
Title or Position _________________
Mailing Address ________________________________________________________
Telephone # ____________________
City ___________________________Postal Code _______________
Email ________________________________________
Name ________________________________________________________________
Title or Position _________________
Mailing Address________________________________________________________
Telephone # ____________________
City ___________________________Postal Code _______________
Email ________________________________________
Page 1 of 4
Ownership of Facility Premises
Does the Licensee own the premises?
Yes
No
If Licensee does not own the laboratory premises:
Lease expiry date:
______/______/______
MM
DD
YEAR
Premises Owner’s:
Name ____________________________________________________________
Telephone # ____________________
Mailing Address ____________________________________________________
Fax # __________________________
City ____________________________ Postal Code _______________ Email ________________________________________
Qualified Professional: (See Appendix A)
Name _________________________________________________________________________________________________
Professional Qualification ________________________________________________
Telephone # ____________________
Mailing Address ________________________________________________________
Fax # __________________________
City ___________________________ Postal Code _______________ Email _________________________________________
Main Laboratory Contact:
Name ________________________________________________________________
Telephone # ____________________
Mailing Address ________________________________________________________
Fax # __________________________
City ___________________________ Postal Code _______________ Email _________________________________________
Signatures:
I/We, in applying for a licence to operate a medical laboratory, state that the information and data contained herein is correct.
I/We hereby authorize the Ministry of Health and the Accreditation Program to share, one with the other, any information
possessed by the Ministry or the Program in relation to my/our provision of medical services in the past and future.
Signature
Name & Title (please print)
Phone #
______________________________ _______________________________________________ _______________________
______________________________ _______________________________________________ _______________________
______________________________ _______________________________________________ _______________________
Updated April 2018
IMPORTANT:
Complete the attached List of Tests.
1.
Complete the attached List of Staff.
2.
Licence # ________________
Page 2 of 4
List of Tests
Name of Test
Updated April 2018
Page 3 of 4
Licence # ________________
List of Staff
Employment
Position
Designation
Cert. Year
Educational
Last Name
First Name
Start
Upgrades
Location in
Professional
Professional
laboratory/clinic
Qualification
Qualification Year
(MM/DD/YEAR)
Updated April 2018
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