Republic of the Philippines Department of Health East Avenue Medical Center

NATIONAL REFERENCE LABORATORY

East Avenue, Diliman, Quezon City Tel. No./Fax No..: 435-71-36; E-mail: nrleamcdoh@yahoo.com

SEMINAR / WORKSHOP ON THE MANUAL OF OPERATIONS FOR DRUG TESTING LABORATORIES PRE-REGISTRATION FORM NOTE: 1. TYPE OR PRINT IN BLOCK LETTERS 2. BRING THIS REGISTRATION FORM DURING SEMINAR/WORKSHOP Registration No.: Date: Please choose one and check ( ) Head of the Laboratory Sex: PRC ID No. ( ) Analyst

Name of Participant: (Family Name, First Name, Middle Name) Profession: Name of Institution/Agency/Laboratory: Address (Laboratory): Address (Home):

Head of the Laboratory Telephone No.: Cell Phone No.:

NRL PRE-REGISTRATION FORM

Fax No.: Email Address:

--------------------------------------------------CUT HERE---------------------------------------------------Registration No.: Name of Participant: Total Amount Paid: Received by:
(Printed Name and Signature)

FOR NRL USE ONLY Date and Time Received O.R. No. & Date of Issuance