, after having been duly sworn to in accordance with law hereby voluntarily depose and state: 1. That I am the lawful registered owner/legal person/radiation protection officer of with business address at . 2. That prior to the renewal of my license to operate (LTO)/certificate of compliance (COC) an x-ray facility for the year , I am faithf.
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How to fill out the PH Affidavit Of Continuous Compliance online
Filling out the PH Affidavit Of Continuous Compliance is an important step in ensuring that your x-ray facility meets regulatory requirements. This guide provides clear instructions for completing the form online, ensuring a smooth process for users at all experience levels.
Follow the steps to fill out the PH Affidavit Of Continuous Compliance with ease.
- Click ‘Get Form’ button to access the document and open it in your preferred online editor.
- In the first section, provide your full name, indicating your legal age and your marital status. Fill in your complete residential address to confirm your identity.
- Next, declare your position by stating whether you are the lawful registered owner, legal person, or radiation protection officer of the x-ray facility. Enter the business name of the facility and its address.
- For the upcoming year, indicate the year for which you are renewing your license to operate or certificate of compliance. Ensure that this reflects the current year of operation.
- Affirm your compliance by stating your commitment to fulfilling the licensing requirements set by the Department of Health for your facility.
- In the next section, acknowledge that if the Health Physics/Enforcement team finds deficiencies during monitoring or inspection, you will accept any sanctions imposed by the regulatory body.
- Make clear that this affidavit absolves the Center for Device Regulation, Radiation Health, and Research of any legal responsibility concerning your license renewal.
- Finally, sign the affidavit to authenticate your statements. Include the date and the location where you are signing. Ensure your signature is clear.
- After completing all fields, save your changes. You can then download, print, or share the completed form as needed.
Complete your PH Affidavit Of Continuous Compliance online today to ensure uninterrupted operation of your x-ray facility.
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