LAMP Enrollment Form

Form Approved
OMB No. 0920-xxxx
Exp. Date xx/xx/20xx

Laborator Enrollment Form
Date

Laborator Information
Information
Laboratory
Lab rat ry Name
Ph ne Number

Fax Number

General Lab rat ry E-mail Address (If applicable)

Website

Mailing Address

Shipping Address (

Address

Address

City

City

State/Pr vince

State/Pr vince

Zip/P stal C de

Zip/P stal C de

C untry

C untry

Same as mailing address.)

Requestor
Requestor Information
Information
Salutation Dr.
First Name

Last Name
Title/P siti n

Degree(s)
MD

Ph.D.

Ph ne Number

Other
Fax Number

E-mail Address

Please complete this form, save it for your records and e-mail it to [email protected].
CDC estimates the average public reporting burden for this collection of information as 10 minutes per response, including the time for reviewing
instructions, searching existing data/information sources, gathering and maintaining the data/information needed, and completing and reviewing the
collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays
a currently valid OMB Control Number. Send comments regarding this burden estimate or any other aspect of this collection of information, including
suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333;
ATTN: PRA (0920-xxxx).