Application for Licensure of X-ray Producing Machines
Idaho Bureau of Laboratories
Radiation Control Program
208-334-0528
For Office Use Only

License #:

License date:

Renewal date: 

In compliance with the provisions of the Idaho Radiation Control Rules IDAPA 16.02.27, the Department of Health and Welfare requires licensure of all X-ray producing machines.  Please notify the Department within ten (10) days of any change in the following information.  This form can be found at www.statelab.idaho.gov on the Lab Certification and X-Ray Licensure page. Required fields are designated with a red asterisk (*).

Note:  Licensure does not imply approval or disapproval of installation.  Licensure does not indicate compliance with all Idaho regulations as applicable to x-ray producing machines.  Inspection reports should be kept as evidence of compliance.
By submitting this form, you are certifying that the information contained herein is true and correct to the best of your knowledge.
Form revised 9/2018
Note:  A facility or group of facilities under one administrative control that employs one or more full-time individuals whose positions are entirely devoted to in-house radiation safety may opt to pay a flat annual facility licensure fee of $1,000.

Standard license fee calculated by (# of tubes * $25) + $50.  Standard license applications must complete the X-ray Producing Machine Listing below.

Application type:*
X-ray License Number:
X-ray License Number:
Facility type:*
2 year license
4 year license
10 year license
Please complete the following information:
Please complete the following information:
License type:*
Annual License Fee:  $1,000
Standard License Fee
Standard License Fee
$
Please attach any necessary documentation for your annual license.
Please attach any necessary documentation for your annual license.
Please include any additional information.
X-ray Producing Machine Listing 
Include ALL X-ray producing machines at your facility.