Follow the steps to complete the registration form correctly.

1. Click the ‘Get Form’ button to access the registration form and open it in your preferred document editor.
2. In section A, provide the registrant information, including the name of your facility, business, or practice, along with the business phone number. Specify the type of facility, such as dental, medical, or veterinary. Include mammography provider details if applicable.
3. Input the physical address by including the street number and name, city, state, and zip code. If the mailing address differs, provide that information as well.
4. Proceed to section B to list all radiation machines in your possession. For each machine, include the manufacturer, model, type code, number of X-ray tubes or electron guns, room name or number, and the acquisition date in mm/dd/yyyy format.
5. In section C, enter contact information for a designated individual who can be reached by a Radiologic Health Branch representative. Include their name, phone number, and email address.
6. Section D requires the signature of an authorized representative. They should declare the accuracy of the information provided and agree to abide by the applicable laws and regulations. Include their name, title/position, signature, and date.
7. Finally, review the recordkeeping/submission instructions in section E. Ensure you submit all pages of the form without multiple copies. Keep a copy for your records, and mail the original along with any supporting documents to the designated address.
8. After completing the form, you may save the changes, download, print, or share the form as needed.

Complete your radiation machine registration form online today to ensure compliance and proper registration.