Kansas Department of Health and Environment
DIVISION OF HEALTH AND ENVIROMENTAL LABORATORIES
Topeka, Kansas
APPLICATION FOR ENVIRONMENTAL FIELD LABORATORY ACCREDITATION

The following information is required in connection with the approval for field Laboratory accreditation

TYPE OF APPLICATION:

Please select the application:*

I. LABORATORY INFORMATION:

Laboratory Name *

Certification Number: *

Physical Location/Address *

City *	State *	Zip *	County *

Fax	Phone *

Federal Tax I.D. # *	Laboratory Website:	Hours of Operation:

Mailing Address *

City *	State *	Zip *	County *

II. LABORATORY CONTACTS:

ExpandColumn	Primary Contact	CT_ID	LabID	CT_ISPrimaryContact	Name	Position	Email	Phone number	Edit Information	Delete Information
Add New Contact Information
	No Contact Information Added to the Registration

III. LABORATORY OWNERSHIP INFORMATION:

ExpandColumn	Owner Name	Address	City	Edit Information	Delete Information
Add Owner of Laboratory Information
	No Laboratory Ownership Information Added to the Registration

IV. FIELDS BEING REQUESTED FOR ACCREDITATION:

Fields *

One Field	$70
Two or more fields	$120
Total Due: $0

V. I hereby make application to the department of Health and Enviroment to be approved for performing certain chemical analyses on samples in accordance with K.S.A. 65-1, 109a. It is understood that before approval can be granted, the laboratory must be in compliance with all requirements as established by the Kansas Department of Health and Enviroment. I certify the information provided with this application is complete, true, and correct, and providing false information is a basis for revocation of laboratory accreditation.

BY SIGNING BELOW, I hereby certify that I am authorized to sign this application on behalf of the applicant/owner and that there are no misrepresentations in my answers to the questions on this application.

Name of person submitting this application *

Title *

Date:

Total Payment Amount

How do you plan to Pay ? *

Notes/Comments: