Get Application For Proficiency Certification For Limited Radiographer - In.gov - Indiana

Filling out the Application For Proficiency Certification For Limited Radiographer can seem daunting, but this guide will provide you with clear and organized steps to complete the application online. By following these instructions, you will ensure that your application is accurate and complete, facilitating timely processing.

Follow the steps to successfully complete your application.

1. Press the ‘Get Form’ button to access the application form and open it in your preferred online editing interface.
2. Begin by entering your personal information in the 'Applicant Information' section. This includes your last name, first name, middle initial, home address, city, state, ZIP code, Social Security number, daytime phone number, and date of birth. Ensure that all information is printed clearly or typed accurately.
3. Proceed to the 'Permit Category' section, and select the appropriate type of permit you are applying for (e.g., cardiac catheterization, chiropractic, chest, dental, or podiatric). Additionally, fill in the expiration date of your current permit, if applicable.
4. In the 'Approved Educational Program' section, provide the name of the school or program you graduated from, the address of the institution, date of graduation, and the date you enrolled in the program.
5. Next, the 'Certifier' section must be completed by a certifying individual. This person will provide their last name, first name, middle initial, address, city, state, ZIP code, and phone number. They will also list their degrees and certifications.
6. Then, complete the 'Evaluation and Certification of Proficiency' section. The certifier must confirm that they instructed you on radiation protection principles and ensured you had clinical instruction and supervision. This section concludes with the certifier's signature and date.
7. Lastly, review your application for any missing or unclear information. After confirming accuracy, you can save changes, download the completed application, print it, or share it as needed.

Complete your application online now to ensure your proficiency certification process is efficient and effective.