Follow the steps to successfully complete your application

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin with Part 1, 'About You.' Fill in your last name, first name, middle name, any other last or maiden names used, date of birth, height, weight, gender, hair color, eye color, driver's license number, and social security number. Ensure all information is accurate.
3. Continue to Part 2, 'Contact Information.' Enter your mailing address (or P.O. Box), city, state, zip code, cell phone number, home phone number, and both personal and work email addresses. Remember, personal contact information is confidential.
4. In Part 3, 'Your Physician Assistant License,' provide your Oregon PA license number, the date it was first issued, the date of the most recent renewal, and the expiration date of your PA license.
5. Move to Part 4, 'Additional Clinical Experience.' Verify that you have covered specific topics in your clinical experience training. For each topic (patient dose reduction, occupational dose reduction, image recording, quality control of fluoroscopic equipment), mark 'Yes' or 'No.'
6. In Part 5, you must review the application agreement carefully. By signing the application, you acknowledge your understanding of the examination policies and requirements outlined.
7. Part 6 consists of the agreement regarding the provision of your social security number. Your SSN is mandatory, and by signing, you confirm that you understand its use and implications.
8. Once all sections are completed, review your application for accuracy and ensure all supporting documents are included. Required documents include a completed examination form, a passport-size photograph, and a payment of $195.00.
9. When ready, save your changes, download, print, or share the completed form as needed, and ensure it is mailed or delivered to the Oregon Board of Medical Imaging.

Ensure you complete and submit your application online accurately to facilitate a smooth permit process.