APPLICATION FOR RADIATION MACHINE …

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[* office use only]Reg. Number: ___ ___ ___ ___ ___ ___Date Rec d: ____________________APPLICATION FOR RADIATION MACHINE facility registration (Rev. 01/2005) Form 1RREGISTRANT INFORMATIONFacility Name: Address (location of MACHINE ): City, State, Zip: Preferred Mailing Address: [ __ ] same as aboveTelephone: Fax: Contact: FEIN: RADIATION MACHINE INFORMATION MACHINE Type(code)MakeModelX-ray tube ( t ) orcontrol ( c ) s/nRoom number orOther location(use additional pages if necessary)*Specialty Code ________* facility Type ________ *County _________________________I certify that the above information is correct. Changes will be reported in writing within 10 daysto the address (required): Date: Print name: WV Department of Health and Human ResourcesBureau for Public HealthOffice of Environmental Health Services350 Capitol Street, Room 313Charleston, WV 25301-3713[* office use only]Reg.

[* office use only] Reg. Number: ___ ___ ___ ___ ___ ___ Date Rec’d: _____ APPLICATION FOR RADIATION MACHINE FACILITY REGISTRATION

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