Transcription of APPLICATION FOR RADIATION MACHINE FACILITY …
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Example: air traffic controller
APPLICATION FOR RADIATION MACHINE FACILITY …
[* office use only]Reg. Number: ___ ___ ___ ___ ___ ___Date Rec d: _____APPLICATION FOR RADIATION MACHINE FACILITY registration (Rev. 01/2005) Form 1 RREGISTRANT INFORMATIONF acility 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.
[* office use only] Reg. Number: ___ ___ ___ ___ ___ ___ Date Rec’d: _____ INSTRUCTIONS FOR COMPLETION OF FORM 1R APPLICATION FOR REGISTRATION OF RADIATION MACHINE ...
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