Idaho Radiation Control Program X-Ray Service Provider Application

Idaho Radiation Control Program
X-Ray Service Provider Application

In compliance with the provisions of the Idaho Radiation Control Rules IDAPA 16.02.27, the Department of Health and Welfare requires registration of all X-ray producing machines. It is your responsibility to notify this department of the Installation or assembly of any type of X-ray producing equipment within the State of Idaho within ten days.

Please complete the following information:

Name of Company:
Contact Person:
Title:
Radiation Safety Officer (if different than contact person):
Physical Address:
Physical City
Physical State
Physical Zip Code
Mailing Address:
Mailing City
Mailing State
Mailing Zip Code
Telephone:
Fax Number:
Email:

If applicable, please list all employees performing work in Idaho.

Type of equipment serviced/assembled:

	Dental
	Industrial
	Medical
	Therapy
	Veterinary

Please attach a copy of form FDA 2579 to inform us of any installation (if applicable).

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