Get Form3r Physicist 11-2013.pdf - West Virginia Department Of Health ... - Wvdhhr

This guide provides a comprehensive overview of how to fill out the Form3r Physicist 11-2013.pdf from the West Virginia Department Of Health. By following these detailed steps, you will be able to submit your application efficiently and accurately.

Follow the steps to complete the application effectively.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Fill in the applicant information section. This includes the name of the company or individual, the street address, city, county, state, telephone number, ZIP code, fax number, and email address.
3. In the general information section, check all appropriate boxes to indicate the services you will provide, such as general health physics consulting, radiation machine evaluations, shielding design, or MQSA medical physicist.
4. Review the applicant certification section. By signing this application, you affirm your understanding of the relevant regulations. Ensure that you are aware of any reporting requirements or restrictions related to your services.
5. If applicable, include a supervising physicist's signature in the designated area, especially if you are applying for therapy machine evaluation privileges.
6. Include any necessary documents as specified. This may include a resume, educational qualifications, experience, board certification, and a list of facilities served.
7. Sign and date the application form. Make sure to keep a copy of your application and any correspondence.
8. Enclose the registration fee of $120.00 with your application. Ensure that your payment is made by check or money order payable to WVBPH.
9. Submit the completed application and payment to the designated address for the West Virginia Department of Health and Human Resources.
10. For questions or additional information, contact the Radiological Health Program or explore their resources online.

Take the next step in your application process by completing and submitting your documents online.