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:
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.
If applicable, please list all employees performing work in Idaho.
Type of equipment serviced/assembled:
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).
Please attach a copy of form FDA 2579 to inform us of any installation (if applicable).
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