Follow the steps to complete the Cl 34 form online.

1. Press the ‘Get Form’ button to access the Cl 34 form and open it in your preferred editor.
2. In the first section, provide your name, including your last name, first name, and middle name. If applicable, fill in your maiden name.
3. Enter your mailing address, including the city, state, and zip code. Make sure all details are accurate for correspondence.
4. List your present employer's name and address. Include the employer's CLIA license number and Medicare provider number.
5. Specifically indicate your employment work arrangements by selecting full-time, part-time, or call/call back options. Include hours worked per week.
6. Indicate your current position in the laboratory by checking the relevant box (e.g., Director, Technologist).
7. For technical supervisors, check all areas in which you currently function, such as microbiology or chemistry.
8. Answer the educational qualifications sections, including whether you are a high school graduate or equivalent, and provide details about colleges or other institutions attended.
9. Provide details on clinical laboratory training, including the name and address of the institution, duration, and the title of the program.
10. List any licenses or certifications you hold, including the title, granting agency, and license number.
11. For proficiency examinations, indicate the type of examination taken and whether you passed it, along with relevant dates.
12. Detail your clinical laboratory experience, following the chronological order from your earliest to your most recent employment.
13. In the remarks section, add any additional information pertinent to your qualifications or experiences not previously included.
14. Read the certification statement carefully, affirming that all the provided information is true, then sign and date the form.
15. If applicable, have the current laboratory director review and sign the form as well.
16. After completing the form, ensure all fields are accurately filled, then save your changes, download, print, or share the completed Cl 34 as needed.

Complete your Cl 34 form online today to ensure your qualifications are properly appraised and meet necessary compliance requirements.