Get X-ray Termination Request Form (rev Dec'09) - Health Nv

The X-ray Termination Request Form is an essential document for notifying the state of Nevada about the termination of registration for ionizing radiation machines. This guide provides clear steps to assist users in filling out the form online accurately and efficiently.

Follow the steps to complete the form with ease.

1. Press the ‘Get Form’ button to access the X-ray Termination Request Form and open it in your chosen editor.
2. Begin by entering the Nevada registration number in the designated field. This number identifies your X-ray machine and is essential for the request.
3. Fill in the registrant's information including the name, street address, city, state, zip code, telephone number, email address, and fax number. Ensure all contact information is accurate for follow-up communication.
4. Provide detailed information about the machine, including its manufacturer, model number, and serial number. This helps validate the termination request.
5. Indicate the transfer or disposal status of the machine. Select the appropriate option from: transferred or sold, put in storage, disassembled, or removed from state. Fill in corresponding dates and additional details as necessary.
6. If you have transferred or sold the machine, enter the name and contact information of the new owner or storage location including address, telephone number, email address, and fax number.
7. If applicable, include an explanation for any other type of disposal or status in the provided section.
8. Sign the form on behalf of the registrant. Include your printed name, title, and the date of signing.
9. Ensure you attach a copy of the completed invoice from the service company that deactivated the machine, as required by NAC 459.030.
10. Review all filled information for accuracy. Save the changes, and choose to download, print, or share the completed form as needed.

Complete your X-ray Termination Request Form online today to ensure a smooth process.