Form 27068 - Application For Radiology License - Indiana State Department Of Health
Download a blank fillable Form 27068 - Application For Radiology License - Indiana State Department Of Health in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form 27068 - Application For Radiology License - Indiana State Department Of Health with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1Reset Form
APPLICATION FOR RADIOLOGY LICENSE
INDIANA STATE DEPARTMENT OF HEALTH
Attn: Cashier’s Office
State Form 27068 (R17 / 5-12)
PO Box 7236
Approved by State Board of Accounts, 2012
Indianapolis, IN 46207-7236
*Your Social Security number is being requested by this state agency in accordance with IC 4-1-8-1; disclosure is mandatory and this record cannot be processed without it.
INSTRUCTIONS:
1. Complete all sections. Missing information may delay processing.
2. Type or clearly print all information.
3. Make a check or money order for $60 payable to: Indiana State Department of Health.
4. If your name has changed since your enrollment in a radiography program, enclose a copy of proof of name change
(marriage certificate, divorce decree, or court order stating the legal name change).
5. Mail the completed application and fee to the address above.
THIS FORM CANNOT BE USED FOR LICENSE RENEWAL.
APPLICANT INFORMATION
First Name
Middle initial
Last Name
Home Address (Number, Street, P. O. Box)
E-mail address (for future license renewal notification)
City
State
ZIP Code
Social Security Number (Required per IC4-1-8-1) *
Daytime Telephone Number (including area code)
Date of Birth
_______ -- _______ -- ____________
(______) _______ -- _____________
______/______/_________
mm
dd
yyyy
LICENSE CATEGORY
Cardiac Catheterization
Chiropractic
Nuclear Medicine
Radiation Therapy
Chest
Dental
Podiatric
Radiologic Technologist
APPROVED EDUCATIONAL PROGRAM
Name of School / Program
Address of School / Program
Date Enrolled
Date Graduated
______/______/______
______/______/______
mm
dd
yyyy
mm
dd
yyyy
PROFESSIONAL INFORMATION
Check appropriate examination / certification you have completed:
Cardiac Catheterization Examination
ARRT Limited Scope Examination
ARRT Radiography
DANB Certified Dental Assistant
ARRT Nuclear Medicine
ASPMA Certification
DANB Radiation Health & Safety
ARRT Radiation Therapy
ASCT Chiropractic Examination
NMTCB Nuclear Medicine
COMPLIANCE INFORMATION
Answer each of the following questions. For any “YES” answer to questions 1 - 4, please provide a complete explanation on a separate
sheet and attach to the application.
1. Have you ever been convicted of a felony?
Yes
No
2. Have you ever been denied or had a license / certification revoked?
Yes
No
3. Have you ever been formally notified of any complaint against you relative to the practice of radiologic technology?
Yes
No
4. Do you have a drug or alcohol abuse problem or any mental or physical disability that, through the practice
of your duties, may be dangerous to patients or public?
Yes
No
Yes
No
5. Are you a high school graduate or GED Certificate holder?
APPLICANT AGREEMENT
In consideration of the granting to me a 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 it’s duly authorized representative, at all reasonable times, opportunity to inspect my 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
If you have any questions, call AC 317/233-7565, Division of Medical Radiology Services or e-mail radiology@isdh.in.gov.
ADVERTISEMENT
0 votes
Related Articles
Related forms
State Form 8200 - Application For License To Operate A Health Faclity - Indiana State Department Of Health
Legal
State Form 45703 - Application For Radon Tester / Mitigator Certification - Indiana State Department Of Health
Legal
Related Categories
Parent category: Legal