Customer Information

Customer Contact

Contact Name*

Company Name and Address


Customer Type

Customer Type*
Only sign section below that applies to customer type selected

Consumer - Home Use

I certify that IvD product labeled as "Professional Use Only" purchased from CLIAwaived, Inc. will:

(1) Only be used for Consumer applications

(2) Not be altered in any way (including not adding or modifying any labeling and

(3) Not be re-sold

and I agree to give CLIAwaived, Inc. 30 days written notice in the event I intend to change this usage in the future.

Name
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Professional Use Certification

I certify that IvD product labeled as "Professional Use Only" purchased from CLIAwaived, Inc. will:

(1) Be used by Professional Users only (ref: license/credential above)

(2) Not be altered in any way (including not adding or modifying any labeling and

(3) Not be re-sold

and I agree to give CLIAwaived, Inc. 30 days written notice in the event I intend to change this usage in the future.

Name
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Forensic Certification

I certify that IvD product labeled as "Professional Use Only" purchased from CLIAwaived, Inc. will:

(1) Only be used for Forensic applications

(2) Not be altered in any way (including not adding or modifying any labeling and

(3) Not be re-sold

and I agree to give CLIAwaived, Inc. 30 days written notice in the event I intend to change this usage in the future.

Name
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Reseller Certification

I certify that IvD product labeled as "Professional Use Only" purchased from CLIAwaived, Inc. will:

(1) Only to be used by and/or re-sold to bonified Professional Users (as evidenced by their credentialed/licensed status) or fto other users who cerfify to a Forensic/Non-Medical use.

(2) Not be altered in any way (including not adding or modifying any labeling

and I agree to give CLIAwaived, Inc. 30 days written notice in the event I intend to change this usage in the future.

Name
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Emergency Use (A device that is not FDA Cleared and not CLIA categorized) Certification

I certify that IvD product labeled as "Professional Use Only" purchased from CLIAwaived, Inc. will:

(1) Only to be used by and/or re-sold to bonified Professional Users (as evidenced by their credentialed/licensed status) or fto other users who cerfify to a Forensic/Non-Medical use.

(2) Not be altered in any way (including not adding or modifying any labeling

and I agree to give CLIAwaived, Inc. 30 days written notice in the event I intend to change this usage in the future.

Name
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Facility Information

Does your facility currently have a laboratory license?
Which of the following best describes your business?*

Check all that apply
Product Interest: Point of Care*

Check one or more areas of interest
Product Interest: Laboratory Testing Systems*

Check one or more areas of interst. Note: May require CLIA Moderate License.
Equipment currently in operation at your facility

Check all that apply
Please send me information on the following
Please check all that apply
Please send me emails with the following product specials and promotions
Check all that apply