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Get and Sign Disclosure of Ownership and Control Interest Form  Azdhs 2005

Get and Sign Disclosure of Ownership and Control Interest Form Azdhs 2005

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IdentifvinQ Information Name of Entity C IIANo. D/B/A Street Address EIN Telephone No. and Fax No. IZip Code City County State II. Item I -Under identifying information specify in what capacity the entity is doing business as DBA for example name of trade or corporation. Item II -Self-explanatory. INSTRUCTIONS FOR COMPLETING DISCLOSURE OF OWNERSHIP AND CONTROL INTEREST STATEMENT Form -1513 SPECIAL FOR CLIA LABORATORIES All CLiA laboratories must complete Part I through VII b of this form....
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