Registration Form for the Voice Response System Physician's License Number or Submitter Code Number : ___  ___  ___  ___  ___  ___ Personal Identification Number (PIN) ___  ___  ___  ___ (Write a four digit number of your choice) Last Name:   _________________________________ First Name:   _________________________________  Middle Initial ___ Primary Contact Information: Street Address/P.O.Box:   _________________________________ Street Address/P.O.Box 2.:   _________________________________ City _____________________ State _______ Zip+4 __________-_______ Phone: (____) _________ Fax (____) _________ E-mail _____________@____________ Secondary Clinic or Office Sites: (Please fill in site information for each site you use as a return address on specimen submissions. Make copies of this sheet if you have more sites than available on this form.) Site Name: _________________________________ Street Address/P.O.Box:   _________________________________ Street Address/P.O.Box 2.:   _________________________________ City _____________________ State _______ Zip+4 __________-_______ Phone: (____) _________ Fax (____) _________ E-mail _____________@____________ Site Name: _________________________________ Street Address/P.O.Box:   _________________________________ Street Address/P.O.Box 2.:   _________________________________ City _____________________ State _______ Zip+4 __________-_______ Phone: (____) _________ Fax (____) _________ E-mail _____________@____________ Site Name: _________________________________ Street Address/P.O.Box:   _________________________________ Street Address/P.O.Box 2.:   _________________________________ City _____________________ State _______ Zip+4 __________-_______ Phone: (____) _________ Fax (____) _________ E-mail _____________@____________   Physician/Submitter's Signature _________________________________  Date______ Mail this form to the following address: Newborn Screening Laboratory (VRS Enrollment) Georgia Public Health Laboratory 1749 Clairmont Road Decatur, GA 30033-4050