Get Application For Provisional Or Student Permit - In.gov - In

Filling out the APPLICATION FOR PROVISIONAL OR STUDENT PERMIT is a vital step for individuals seeking to obtain a permit in radiologic technology. This guide will provide you with clear and detailed instructions to help you complete the form accurately and efficiently.

Follow the steps to successfully complete your application.

1. Press the ‘Get Form’ button to access the application form and open it in your browser.
2. Carefully fill out the applicant information section. Provide your first name, middle initial, last name, and complete home address, including city, state, and ZIP code.
3. Enter your social security number as required by state regulations. This information is mandatory for processing your application.
4. Provide your daytime phone number with the area code, and your date of birth in the specified format: mm/dd/yyyy.
5. Select the appropriate permit category from the options provided, such as Student – Dental or Provisional – Chiropractic.
6. Enter the name of your educational program or school, along with the date you enrolled, the address of the school, and the signature of your program director or instructor.
7. Fill in the date of your graduation or projected graduation, again in the format of mm/dd/yyyy.
8. Respond to the compliance information section by answering the questions regarding felony convictions, license issues, complaints, and any substance abuse or disability concerns.
9. Sign the applicant agreement, acknowledging that you will comply with all regulations and that your information is accurate.
10. Finally, save your changes, then download, print, or share the completed form as needed, before submitting it to the provided address.

Complete your application online today to ensure a smooth processing experience.