Miscellaneous Payment

Fee and Penalty Payment

Please complete the information below and ensure all details are accurate before submitting this form.


First Name	Last Name
License Number If you don’t have a license number, please enter N/A in the text box.	Email

Please select the applicable fee(s) below:


Initial Application: $25	Yes	No
License Renewal: $25	Yes	No
Late Fee (applying within 15 days prior to expiration): $10	Yes	No
Reinstatement Fee (applying after license has expired): $20	Yes	No
Replacement of Physical License (including name changes): $20	Yes	No
Same Day (within 24 regular business hours) Processing: $35	Yes	No
Unlicensed Testing Personnel Identified During Lab Inspection: $100	Yes	No

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