Follow the steps to successfully complete your Radiology Permit application.

1. Press the ‘Get Form’ button to access the application form in your preferred PDF editor.
2. Begin by entering your personal information. This includes your first name, middle name, maiden name, last name, and the permanent name you wish to display on the permit.
3. Confirm your citizenship status by answering the question on U.S. citizenship. If you select 'No', provide your country of nationality and immigration status. Include your current email address for future communication.
4. Fill in your current residence address, including street, city, state, and postal code, along with your telephone number. Repeat this process for your current office address.
5. List the names of all dentists with whom you work and indicate your date of employment.
6. Complete the sections about your birth details, including place of birth, date of birth, age, race, and sex. You will also need to provide your social security number.
7. Indicate your educational background by specifying the ADA-accredited dental assisting or hygiene programs you attended, including your graduation dates and locations.
8. Answer the questions regarding past radiology permits, potential disciplinary actions, substance addiction, and legal convictions. Provide details on an attached sheet if applicable.
9. Check all relevant statements about your qualifications and attach any required supporting documents such as transcripts, certification cards, or proof of seminar completion.
10. Include a recent color photograph of yourself and ensure that all the information is typed accurately. Once all sections are completed, review the application for completeness.
11. Finally, save your changes, download the completed application, and print it. Ensure to include your payment of sixty dollars via check or money order and mail all documents to the Board’s address.

Complete your Radiology Permit Mississippi application online today for a smoother process.