Application for License of Radiation Machine (Ionizing)

Facility Information

Facility Information


Refer to the legal title and/or administrative control of the radiation machine.
Name of Owner (Individual, Hospital, Corporation, etc.):


Do you have a DBA (Doing Business As) name?	Yes	No


DBA Name: Must be exactly as name appears on legal documents.
Owner

Owner


Select type of ownership:	For Profit Corporation	Non-Profit Corporation	Individual
LLC	LLP	Partnership	Political Subdivision
First Name:		Last Name:

Click below to add another owner's name.


Name:
Address:
Address Line 2:
City:	State:	ZIP Code:	Telephone Number:

Contact Information

Contact Information


Telephone Number:	Extension:	Fax Number:
Facility Contact

Facility Contact


First Name:	Last Name:	Email:

Physical Address

Physical Address


Attention To:
Address of Facility:
Address Line 2:
City:	County:	State:	ZIP Code:

Mailing Address

Mailing Address


Is your mailing address different from the address above?	Yes	No


Attention To:
Mailing Address:
Address Line 2:
City:	State:	ZIP Code:

Type of Facility

Type of Facility


Please select the type of facility according to its primary usage:	Chiropractic	Private Dental Practice
	Educational Institution	Hospital
	Mammography	Medical Clinic
	Nuclear Medicine	Podiatry
	Sales	Veterinarian
	Other	Specify:

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