Customer Change FormDate Submitted & Year For EnrollmentToday's Date *This request is for enrollment year: *Identification InformationWSLH PT ID (7 Digits) CLIA ID Application in progress, CLIA ID not yet received Contact Information of person completing this formFacility Name *Contact Name *Phone *Example: 123-456-7890Email *Request To Change Correspondence/Demographic InformationFacility Name Contact Name Address Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountryAfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiaComorosCongo (Brazzaville)CongoCosta RicaCote d\'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor Timur)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalestinian TerritoryPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint VincentSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited States of AmericaUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamWestern SaharaWestern SamoaYemenZambiaZimbabwePhone Example: 123-456-7890Fax Email Change Pertains To: (check all that apply) Billing InformationShipping InformationSend Reports to InformationRequest To Change Accreditation Agency(ies)Agency Name ID Number Add or Remove AddRemove Agency Name ID Number Add or Remove AddRemove Agency Name ID Number Add or Remove AddRemoveRequest To Add And/Or Drop ProductsProduct Name/Description Year/Event(s) Item# Quantity Indicate ADD or DROP AddDrop Product Name/Description Year/Event(s) Item# Quantity Indicate ADD or DROP AddDrop Product Name/Description Year/Event(s) Item# Quantity Indicate ADD or DROP AddDrop Product Name/Description Year/Event(s) Item# Quantity Indicate ADD or DROP AddDrop Product Name/Description Year/Event(s) Item# Quantity Indicate ADD or DROP AddDrop Product Name/Description Year/Event(s) Item# Quantity Indicate ADD or DROP AddDrop Product Name/Description Year/Event(s) Item# Quantity Indicate ADD or DROP AddDrop Product Name/Description Year/Event(s) Item# Quantity Indicate ADD or DROP AddDropScore Transmission To Accreditation Agency(ies) All applicable scores will be sent to designated agencies by default unless specified below.Do NOT send the following scores to agencies: Added Products: Indicate Method Of PaymentBill Me: PO# to reference on invoice: VISA/MC: If you wish to pay by credit card, please wait for your invoice for instructions. Dropped Products Cancellations and/or adjustments after enrollments and orders have been processed and/or paid will be handled on a case by case basis. All requests must be submitted in writing at least 30 days prior to a scheduled shipment date. The annual processing fee is non–refundable.Dropped Products: Indicate Reason For DropReason products dropped No longer performing this testIncorrect initial orderChanged instrument or kitSite closedOther - please explainExplain Other Here: VerificationPlease enter any two digits *Example: 12 This step is to verify this form is being completed by a person and not a computer.This box is for spam protection - please leave it blank: