Maryland Laboratory Licensing Change Form

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Change of Director, a copy of the Director’s medical license, medical diploma and board certification must be submitted. Please send diploma and CV for a PhD Director. This form must be signed by the Director for these changes to be valid. ***THIS FORM MUST BE SIGNED BY THE DIRECTOR FOR ALL CHANGES TO BE VALID.*** Please return this form by fax: 410-402-8213 Or by mail: Attention: Lab Licensing, OHCQ – Bland Bryant Building, 55 Wade Avenue, 1st Floor, Catonsville, MD 21228 Current Name of Lab:...

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