Get Facility Registration Approval Request Form (pdf) - Department Of ...

The Facility Registration Approval Request Form is essential for any facility planning to install an x-ray producing machine. This guide provides step-by-step instructions on how to accurately complete the form online, ensuring that all required information is correctly submitted.

Follow the steps to successfully fill out the Facility Registration Approval Request Form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Indicate the purpose for your request by checking the appropriate box for new facility, relocation, or acquisition of an existing facility. Provide the existing address and registration number if applicable.
3. Fill in the facility name, location address, and contact person details, including their phone number and mailing address.
4. Provide the email address and fax number for contact purposes.
5. Enter the name of the Radiation Safety Officer (RSO) and their qualifications in the designated sections.
6. List all doctors practicing at the facility along with their license numbers and expiration dates.
7. Specify the type of equipment to be installed and the facility type by referring to the provided lists.
8. Indicate whether the installation will involve digital equipment by circling Yes or No.
9. Provide the expected date of installation and the shielding plan log number if applicable.
10. Fill in details about the x-ray equipment, including the manufacturer, model number, and type.
11. List the vendor preparing the shielding plan and the vendor selling or installing the equipment, including their contact details.
12. Ensure you enclose the required documents, including the application fee, and sign the form in the designated area for the RSO.
13. After completing the form, you can save your changes, download a copy, print, or share the completed document as needed.

Complete your Facility Registration Approval Request Form online to ensure a smooth application process.