Form 08-4420 - Radiological Equipment Registration Form - Department Of Community And Economic Development

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DEN
STATE OF ALASKA
FOR OFFICE USE ONLY
DEPARTMENT OF COMMUNITY AND
ECONOMIC DEVELOPMENT
DIVISION OF OCCUPATIONAL LICENSING
REGISTRATION NUMBER:
BOARD OF DENTAL EXAMINERS
P.O. BOX 110806
JUNEAU, AK 99811-0806
(907) 465-2542
E-mail: license@dced.state.ak.us
RADIOLOGICAL EQUIPMENT REGISTRATION FORM
(Use one form for each control panel)
Type of Equipment:
Intraoral Film
Extraoral Film
Combination
Control Panel Serial Number of Equipment:
Control Panel Model Number:
Manufacturer:
Installation Date:
Tubeheads
1) Serial Number/Identifier or Identifying Mark:
Model:
Manufacturer:
2) Serial Number/Identifier or Identifying Mark:
Model:
Manufacturer:
3) Serial Number/Identifier or Identifying Mark:
Model:
Manufacturer:
4) Serial Number/Identifier or Identifying Mark:
Model:
Manufacturer:
Physical Location of Equipment:
Name of Owner(s) or Lessee(s) of Equipment:
Address of Owner(s) or Lessee(s)
of Equipment:
Telephone Number of Owner(s) or Lessee(s):
Name and License Number of Dentists
where equipment is located:
Please complete, per 12 AAC 28.960, and return to the State of Alaska.
08-4420 (New 1/00)

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