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APPLICATION FOR RADIOLOGY LICENSE OR PERMIT
State Form 27068 (R14 / 1-09) Approved by State Board of Accounts, 2009

INSTRUCTIONS:

1. Fill out all blocks. This application will be returned to you without processing if any information is missing. If an item does not apply put "NA" in that block. Do not use abbreviations in any area on the application. 2. Type or clearly print all information. 3. Make a personal check or money order for $60 payable to: Indiana State Department of Health. (No fee is required for student or provisional permits.) 4. Send the completed form and fee to: Indiana State Department of Health, ATTN: Cashier's Offices, P.O. Box 7236, Indianapolis, IN 46207-7236. 5. You will receive your certificate from the Division of Medical Radiology Services or a letter indicating why your application was rejected. 6. If you have any questions, call AC 317/233-7565 Division of Medical Radiology Services or e-mail [email protected]. 7. The disclosure of your Social Security Number is required in accordance with IC 4-1-8-1.

Applicant Information:
Last Name: First Name: MI:

Home Address (number, street, P. O. Box):

City:

State:

9 Digit Zip Code:

Social Security Number:

Home Phone Number: (Including area code) ( )

Date of Birth: (mm/dd/yyyy)

Category of Permit or License: Select one category of Permit or License (check one box only)
PERMIT: Student Radiography Student Radiation Therapy Student Nuclear Medicine Student Dental Radiography Provisional Chiropractic LICENSE: Limited Chest Limited Chiropractic Radiologic Technologist Limited Dental Limited Cardiac Catheterization Nuclear Medicine Technologist Limited Podiatric Radiation Therapy Provisional Dental Provisional Chest Provisional Podiatric

High School Education Information Have you graduated from high school? If yes, indicate the date: Yes or No
____/____/____
(mm / dd /yyyy)

If G.E.D., give number and date:

High school: _______________________ Location:___________________________

Approved Educational Program: Name of School: Location of School:

Date Enrolled (mm/dd/yyyy):

Date Graduated or Projected to Graduate:
(mm/dd/yyyy)

Professional Information: (License only) Check appropriate professional examination/certification you have completed (if any):
ARRT Radiography Certification ARRT Limited Scope Examination DANB Certified Dental Assistant ASPMA Certification

DANB Dental Radiation Health and Safety Examination

NMTCB Nuclear Medicine

ARRT Radiation Therapy Certification

Compliance Information: Answer each of the following questions "Yes" or "No". If you answer any of the questions "Yes", please provide a complete explanation on a separate sheet. Have you ever been convicted of a felony? Have you ever been denied or had a license/certification revoked? Have you ever been formally notified of any complaint against you relative to the practice of radiologic technology? Do you have a drug or an alcohol abuse problem or any mental or physical disability that, through the practice of your duties, may be dangerous to patients or public? Applicant Agreement: In consideration of the granting to me a permit/license, I do hereby agree to abide by all the rules and regulations of the Indiana State Department of Health, and to permit the Department, or its duly authorized representative, at all reasonable times, opportunity to inspect my permit/license. I also declare, subject to the penalties for perjury, that all data appearing on this application is accurate and true to the best of my knowledge. I hereby authorize the release of any and all educational information concerning this application to the Indiana State Department of Health. Yes Yes Yes No No No

Yes

No

Signature of Applicant: ______________________________________ Date Signed: _______________
(mm/dd/yyyy)

BEFORE YOU MAIL YOUR APPLICATION:
1. Have all questions been answered? 2. Is your application signed? 3. Have you enclosed your license fee?
4.

If your name has changed since you enrolled in a radiography program, enclose a copy of your proof of name change (copy of marriage certificate, divorce decree, or court order stating the legal name change).