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Get NJ CL-4 2016-2024

CENSE (CLIA WAIVED TESTS ONLY) FOR STATE USE ONLY Received By Check/E-Pmt. Rec’d Approved By Renewal ($200 Fee) LABORATORY INFORMATION Name of Laboratory NJ CLIS ID Number (7 digit number) Laboratory Address (Street Address/PO Box) CLIA Number (City, State, Zip Code) Facility Type (Select one) Physician Office Laboratory School City County Home Health Agency Pharmacy Associated Clinic Health Screening (incl. Mobile) Other: ____________ Mailing Address [where License(s) should be maile.

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