PEQAS

Proficiency Testing Application Form

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1 Laboratory Details

Laboratory Name *

Affiliation

Address

Country *

Telephone

Email *

2 Contact Person

Full Name *

Position / Title

Phone Number

Email

3 Scheme Details

Discipline *

Sub-discipline *

Scheme 1

Scheme 2

Please select the tissues that your laboratory usually receives for processing:

Bone

Brain

Breast

Male genito-urinary organs (Penis, Testes, Prostate)

Female genital organs (Ovaries, Vagina, Uterus)

GIT (Oesophagus, Stomach, Liver, Gallbladder, Pancreas)

Head & Neck and Endocrine glands

Kidney

Lung

Lymphoid tissue (Lymph Nodes, Spleen & Thymus)

Skin

Soft tissue

Other (Please specify)

4 Declaration

I hereby apply to participate in the PEQAS Proficiency Testing Program. I declare that the information provided is correct and agree to comply with the terms and conditions set by PEQAS.

Authorized Representative *

Date *

I agree to the declaration above and accept the terms and conditions.

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