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Form 27068 - Application For Radiology License Or Permit - Indiana State Department Of Health Page 2

Professional Information: (License only)

Check appropriate professional examination/certification you have completed (if any):

ARRT Radiography

ARRT Limited Scope

DANB Certified Dental

Certification

Examination

Assistant

DANB Dental Radiation Health and

NMTCB Nuclear

ARRT Radiation Therapy

Safety Examination

Medicine

Certification

Compliance Information:

Answer each of the following questions “Yes” or “No”. If you answer any of the questions “Yes”, please

provide a complete explanation on a separate sheet.

Have you ever been convicted of a felony?

Yes

Have you ever been denied or had a license/certification revoked?

Yes

Have you ever been formally notified of any complaint against you relative

Yes

to the practice of radiologic technology?

Do you have a drug or an alcohol abuse problem or any mental or physical

disability that, through the practice of your duties, may be dangerous

Yes

to patients or public?

Applicant Agreement:

In consideration of the granting to me a permit/license, I do hereby agree to abide by all the rules and regulations

of the Indiana State Department of Health, and to permit the Department, or its duly authorized representative, at

all reasonable times, opportunity to inspect my permit/license.

I also declare, subject to the penalties for perjury, that all data appearing on this application is accurate and true

to the best of my knowledge. I hereby authorize the release of any and all educational information concerning this

application to the Indiana State Department of Health.

Signature of Applicant: ______________________________________ Date Signed: _______________

(mm/dd/yyyy)

BEFORE YOU MAIL YOUR APPLICATION:

1. Have all questions been answered?

2. Is your application signed?

3. Have you enclosed your license fee?

If your name has changed since you enrolled in a radiography program, enclose a copy of your proof of name change

(copy of marriage certificate, divorce decree, or court order stating the legal name change).

Form 27068 - Application For Radiology License Or Permit - Indiana State Department Of Health Page 2