FEES PAYABLE

To……………………………………….……..
…………………………………………………..
………………………………………………..…

Dear Sir/ Madam,

Further to your application for

………………………………………………………………………………………………………………….

Of…………………………………………………………………..........., the following table shows the amount you are

suppose to pay.

AMOUNT AMOUNT RECEIPT NO. REMARKS

PAYABLE PAID
ITEM ITEM TO BE PAID FOR (tick where applicable)

1 2 3 4 5

1 APPLICATION FEE

2 INSPECTION FEE

3 RE INSPECTION FEE

4 REGISTRATION FEE

5 ANNUAL INSPECTION FEE

Please note in case of unsuccessful applications appropriate fees will be made to the applicant.

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REMARKS; 1. Non refundable
2. Refundable
3. Paid once
4. Paid Yearly
5. Paid for each application

REGISTRAR……………………………………………………………………………………………………

SIGNATURE………………………………………………………………………………….

FOR OFFICIAL USE ONLY.

Form sent on ………………………………………….. Amount received ………………………………………………………

Serial No…………………………………………………. Date received ……………………………………………………………

Date received back………………………………… Official receipt ……………………………………………………………

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 Date………………….....
Our Ref:______________________________

Your Ref:_____________________________

APPLICATION FOR APPROVAL TO OPERATE PRIVATE MEDICAL LABORATORY

PART 1

TO BE FILLED BY THE APPLICANT IN BLOCK LETTERS IN APPLICANTS OWN HAND WRITING

1. NAME OF LABORATORY/INSTITUTION…………………….………………………………………………………

2. NAME/NAMES OF DIRECTOR (S)

(a) ID/PP No

(b) ID/PP No

(c) ID/PP No

3. PERMANENT ADDRESS OF INSTITUTION

(a) Post Office Box CODE (i) Plot No.

(b) Telephone No. (j) LR No.

(c) Cell Phone No. (If any) (k)Town Center

(d) Fax No. (l) Estate/Village

(e) E-mail (m) County

(f) Road/ Street (n) Province

(g) Premise Name/Blg (o) Land mark

(h) Stand alone/ Attached

4. DATE OF ESTABLISHMENT

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5. WORK LOAD (TICK AS APPROPRIATE FROM THE LIST PROVIDED)

6. (a) NAME OF SUPERINTENDENT LAB TECHNOLOGIST

(b) PROFESSIONAL QUALIFICATION(S)

(a)

(b)

(c)

(ATTACH LEGIBLE CERTIFIED COPIES OF RELEVANT DOCUMENTS, WHERE OBTAINED AND

CONTACT ADDRESS)

(c) LABORATORY TECHNICIAN(S)/TECHNOLOGIST(S) WORKING IN THE FACILITY:

Name Qualification KMLTTB

Registration Status

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 6 (d) Ownership of the company

(i) Sole Proprietor

(ii) Partnership

(iii) A Limited Company

6 (e) In case of (i) above, provide the registration of company bearing the lab
superintendent names (BN)

In case of (ii) above the lab technologist must be the majority share holder and must attach
approve of the same inform of an affidavit.

In case of (iii) above the superintendent technologist must be the majority share holder and

In case where such a technologist is not a shareholder, the lab technologist must be
appointed in writing and the board will recognize acceptance letter (please see annex 1).

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AFPL ANNEX 1

THE ROLE OF A LABORATORY SUPERITENDENT

The superintendent laboratory technologist is the person whose academic certificates, Registration
certificate and valid practice license has been forwarded to the Board for the purpose of the
registration of the premises

ELIGIBILITY TO SUPERITENDENT

1. A laboratory technologist shall only be legible to superintendent over a registered premise

if she/he holds a valid practice license.

2. A laboratory Technologist shall be eligible to superintendent over premises registered by

the board if she/he has worked under supervision of another qualified laboratory
superintendent for a period not less than 5 years from the time of obtaining a diploma or
degree in laboratory science.

3. Any person(s) who wants to apply for registration of premises shall complete the
application forms in his own hand writing and provide all the necessary documents as may
be prescribed by the Board.

4. One person shall only be eligible to superintendent over one registered premise.

5. A reasonable distance shall be maintained between two registered premises to discourage

unfair competition.

6. A body corporate/ Limited liability company may apply to operate more than one premise
(as branches.) However the requirement stipulated in the KMLTTB act must be adhered to
including that each set of premise, there shall be a different superintendent laboratory
Technologist.

7. The board shall be notified in writing at least 30 days prior to any changes affecting the
following :

i. Change of ownership-including share distribution, change of directors etc.

ii. Superintendent laboratory technologist
iii. Change in registered premises i.e Location Plot number, building etc.
iv. Nature of business i.e change of laboratories class.
v. Any other significant changes

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 7. FULL NAMES OF APPLICANT

8. SIGNATURE AND OFFICIAL STAMP OF THE INSTITUTION

9. DATE OF APPLICATION

PART II

DECLARATION BY APLICANT

(To be filled in Capital Letters)

I (Full Name)

Declare that:-

(a) I am eighteen/over eighteen years old.

(b) I am to the best of my knowledge in a physical and mental state of health to be able to
carry out the responsibilities required of me by the profession.

(c) I have not impersonated anybody on any issue related to the profession or otherwise.

(d) I have not altered, falsified or uttered any document/(s) related to the profession or
otherwise.

(e) I am free from any criminal record/(s), conviction/(s) related to the profession or
otherwise.

(f) I am of good profession/ethical standing as required by the professional Code of

Conduct and Ethics

(g) I will at all times in the practice of my profession observe and strictly maintain
Adherence to the provisions and requirements of the professional Code of Conduct and
Ethics.

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 PART III

FOR OFFICIAL USE ONLY

(Delete whichever is not applicable) RG

TS

Date of Application Application No.

Date Application Received Receipt No.

Approved/Not Approved Serial No.

Date

NOTE: ONLY ORIGINAL COPIES WILL BE ACCEPTED