Form Cdph 8391 - Report Of Name Or Address Change - State Of California-Health And Human Services Agency

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State of California-Health and Human Services Agency
California Department of Public Health
Radiologic Health Branch
REPORT OF NAME OR ADDRESS CHANGE
California Code of Regulations, title 17, sections 30406 and 30537, requires any individual
issued
an
X-ray
Technician
Limited
Permit,
Radiologic
Technology
Certificate,
Mammographic Certificate, Fluoroscopic Certificate, Supervisor and Operator Certificate or
Permit, or a Nuclear Medicine Technologist Certificate to report any change in their name or
address within 30 days to this Department.
Pursuant to the California Code of Civil Procedure Section 1275, name change requests must
be accompanied by a copy of a certified superior court order allowing the name change and a
government issued picture ID, such as a driver’s license, military ID, or passport.
Mark only if you are in the process of applying/taking the following State examination:
Supervisor/Operator
Radiologic Technologist
Limited Permit X-Ray Technician
Fluoroscopic Radiologic Technologist
Nuclear Medicine Technologist
Mammographic Radiologic Technologist
Current Certificate/Permit Number _______________
PREVIOUS NAME AND ADDRESS:
Name __________________________________________
Address ________________________________________
City, State, Zip Code _________________________________________________________
CURRENT NAME AND ADDRESS:
Name _________________________________________
Address _______________________________________
City, State, Zip Code _________________________________________________________
Daytime Telephone __________________________E-mail Address____________________
Signature_____________________________________________ Date________________
MAIL OR FAX TO:
California Department of Public Health
Radiologic Health Branch, MS 7610
P.O. Box Number 997414
Sacramento, CA 95899-7414
FAX (916) 440-7999
Telephone (916) 327–5106
Internet Address:
CDPH 8391 (4/11)

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