VERIFICATION OF LICENSURE FOR RADIATION TECHNOLOGIST OR TECHNICIAN

The Delaware Radiation Control Regulations require state certification of 
radiation technologists and technicians who administer radiation to patients in 
the healing arts.  Licensed practitioners such as physicians, dentists, 
veterinarians, and certified dental assistants are exempt from this 
certification requirement.

Complete the top portion of this form with name, social security number, date of 
birth, and Delaware certification number of the individual.  Please allow three 
weeks for processing.  Incomplete forms will be returned.  Fax this form with 
your request on company letterhead to 302-739-3839, or mail to the following 
address:

Delaware Division of Public Health 
Office of Radiation Control
417 Federal Street
Dover, DE  19901

Name:___________________________________________________________________________
	
Social Security Number: ________________________________________________________

Date of Birth:_______________________ Certification #___________________________

================================================================================

For office use, only

Status:		() Current		Expiration Date:  _______________________	

     		() Expired/Terminated

	   	() No record of this individual

Verified by: ___________________________________________________  


Date: _____________________________________________________		Board Seal


To download forms or obtain a copy of the regulations, please visit our web site 
at http://www.dhss.delaware.gov/dhss/dph/hsp/orc.html

DELAWARE DIVISION OF PUBLIC HEALTH
OFFICE OF RADIATION CONTROL
417 FEDERAL STREET
DOVER, DELAWARE  19901              
             
ORC-R16C		   	35-05-20/06/12/10			10/2006