Free Analyst Application to Perform Alcohol Tests-F-62502 - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance F-62502 (Rev. 07/08)

STATE OF WISCONSIN Chapter 343.305(6)(a), Wis. Stats.

ANALYST APPLICATION TO PERFORM ALCOHOL TESTS

Complete this form to request a permit to perform blood and/or urine alcohol tests per Chapter 343.305(6)(a), Wis. Stats. The permit is valid for one year beginning January 1 and ending December 31 and is subject to suspension or revocation if proficiency monitoring reveals an unsatisfactory quality of testing performance. Personal information collected on this form will be used for permit approval purposes only. Failure to provide complete information will result in a delay of permit approval. Collection of the applicant's social security number is required by Chapter 343.305(6)(e) and 73.0301, Wis. Stats. Failure to supply the number may result in the denial of the application. The number will be disclosed only to the Department of Revenue for use in collection of tax delinquencies and to the Department of Workforce Development for use in administration of child and spousal support programs.



RETURN THIS APPLICATION TO:

Supervisor, Clinical Laboratory Unit Division of Quality Assurance P.O. Box 2969 Madison, WI 53701-2969

MINIMUM REQUIREMENTS FOR PERMIT 1. A bachelor's degree in chemistry, or related scientific discipline, and two years of pertinent chemical laboratory experience. 2. In lieu of requirements in item 1, four years of college education, or four years of clinical or chemistry laboratory experience, or equivalent combinations of education and experience.
Name - Applicant (Print clearly or type.) Address City Social Security Number State Zip Code

College or University

City

State

Degree

Year Conferred

Major

Chemistry Credits Semester Quarter Organization

Registration By Year Number

Pertinent Testing Experience (Specify and / or attach current resume.)

Employer(s) (Include Current Employer.)
Name Address Dates Employed

SIGNATURE ­ Applicant

Title (if any)

Date Signed