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 IQAP Hematology Enrollment Form
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New Enrollment Add Instrument Change
* Institution Name:
* Address:
* City:
State:
Zip Code:
* Country:
* Telephone:
Ext:
Email:
* Contact Person:
Calibration Method: S-Cal® Kit   Fresh Blood  
Other:  (Specify)
* What primary or secondary controls do you use?
4C® Plus 5C® 4C®-ES
5C®-ES Retic-CTM Other
If other, specify Product
Beckman Coulter Instrument/s: Diskette Size:
* Type: * Serial No.: * No. of Shifts: 5¼ 3½
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