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Click ‘Get Form’ to open the DOH-2973(f) in the editor.
Begin with Part I, entering the name of the bank, address, city, state, zip code, and telephone number. Ensure all information is accurate as it is crucial for your application.
Move to Part II – Ownership Information. If the owner’s name differs from the tissue bank name, provide the owner's name and address. Define direct and indirect ownership interests as outlined in the form.
Answer whether any owners or board members have ownership interests in other licensed facilities. If yes, list their names and addresses.
In Part III – Declaration, indicate if any individuals have been convicted of healthcare fraud or related charges. Provide details if applicable.
Complete Part IV by signing and dating the form. Include your title and contact information before submission.

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