CoreOne - LCP

Application to Become a Registered Laboratory for Hemp-Derived Cannabinoid

Laboratory Name and Physical Address

* Name

* Physical Address Line 1

Physical Address Line 2

* Physical City

* Physical State

* Physical Zipcode

* Physical County

* Phone #1

Phone #2

* Email

Laboratory Mailing Address

* Is the Mailing Address the same as Physical Address? (If "No", please provide the Mailing Address)

Mailing Address Line 1

Mailing Address Line 2

Mailing City

Mailing State

Mailing Zipcode

Mailing County

Laboratory Director

* Laboratory Director Name

* Laboratory Director Phone Number

* Laboratory Director Email Address

Designated Contact Person

* Designated Contact Person Name

* Designated Contact Person Phone Number

* Designated Contact Person Email Address

Additional Laboratory Information

* Laboratory Opening Date

* Expiration Date of Accreditation

* What type of products is the laboratory testing?

* Business Days and Hours of Operation (Please provide the days and hours the business is open.)

* Time Zone (for Hours of Operation)

* What type of laboratory testing registration are you applying for? (Please select all that apply.)

If type testing includes Hemp-Derived Cannabinoids:

* Please acknowledge that the laboratory testing includes: Delta-8 tetrahydrocannabinol, Delta-9 tetrahydrocannabinol, Delta-10 tetrahydrocannabinol, Hexahydrocannabinol (HHC), Tetrahydrocannabiphorol (THCp), Tetrahydrocannabivarin (THCv), Tetrahydrocannabinolic acid (THCa).

Yes

No

N/A

If type testing includes Residual Solvents and Manufacturing Chemicals:

* Please acknowledge that the laboratory testing includes: Acetone, Benzene, Butanes (measured as the cumulative residue of n-butane and iso-butane), Ethanol, Ethyl Acetate, Heptanes, Hexanes (measured as the cumulative residue of n-hexane, 2-methylpentane, 3-methylpentane, 2,2-dimethylbutane, and 2,3-dimethylbutane), Methanol, Pentanes (measured as the cumulative residue of n-pentane, iso-pentane, and neo-pentane), Propane, Toluene, and Total Xylenes (measured as the cumulative residue of 1,2-dimethylbenzene, 1,3-dimethylbenzene, and 1,4-dimethylbenzene, and the non-xylene, ethylbenzene).

Yes

No

N/A

If type testing includes Residual Pesticides:

* Please acknowledge that the laboratory testing includes: Abamectin, Acephate, Acequinocyl, Acetamiprid, Aldicarb, Azoxystrobin, Bifenazate, Bifenthrin, Boscalid, Carbaryl, Carbofuran, Chlorantraniliprole, Chlorfenapyr, Chlormequat Chloride, Chlorpyrifos, Clofentezine, Cyfluthrin,Cypermethrin, Daminozide, DDVP (Dichlorvos), Diazinon Dimethoate, Ethoprophos, Etofenprox, Etoxazole, Fenoxycarb, Fenpyroximate, Fipronil, Flonicamid, Fludioxonil, Hexythiazox, Imazalil, Imidacloprid, Kresoxim-methy, Malathion, Metalaxyl, Methiocarb, Methomyl, Methyl parathion, Myclobutanil, Naled, Oxamyl, Paclobutrazol, Permethrins (measured as the cumulative residue of cis- and trans-isomers), Phosmet, Piperonyl butoxide, Prallethrin, Propiconazole, Propoxur, Pyrethrins (measured as the cumulative residue of pyrethrin 1, cinerin 1 and jasmolin 1), Pyridaben, Spinosad, Spiromesifen, Spirotetramat, Spiroxamine, Tebuconazole, Thiacloprid, Thiamethoxam, and Trifloxystrobin.

Yes

No

N/A

* Is the laboratory subcontracting/doing send-out for any testing?

* Provide the Web address used to host COAs produced by the laboratory.

I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT. I FULLY UNDERSTAND THAT ANY DEVIATION FROM THE ABOVE WITHOUT PRIOR PERMISSION FROM THIS STATE REGULATORY AGENCY MAY NULLIFY FINAL APPROVAL.

* Applicant's Name

* Applicant's Signature

* Date

ACCEPTANCE OF THE APPLICATION BY THIS REGULATORY AUTHORITY DOES NOT INDICATE FINAL APPROVAL FOR REGISTRATION. ADDITIONALLY, ACCEPTANCE OF THIS APPLICATION BY THIS REGULATORY AUTHORITY DOES NOT INDICATE COMPLIANCE WITH ANY OTHER CODE, LAW, OR REGULATION THAT MAY BE REQUIRED – FEDERAL, STATE, OR LOCAL.

If "Please Wait" does not replace the submit button and no confirmation appears after clicking "Submit," please review the questions above and answer any required ones marked in red.

Tennessee Department of Agriculture

Consumer and Industry Services

Hemp-Derived Cannabinoid Third Party Lab Registration Application

Application to Become a Registered Laboratory for Hemp-Derived Cannabinoid