PO BOX 144103 2026

1. Click ‘Get Form’ to open the PO BOX 144103 document in the editor.
2. Begin by filling out the 'Facility Information' section. Enter the facility name, street address, and mailing address as required. Ensure all fields are completed accurately.
3. Next, provide details for the 'Action Requested' section. Select whether you are applying for an initial certificate, renewal, or a change of ownership. Attach any necessary documentation as specified.
4. In the 'Staff Information' section, input the license numbers for both the radiology technologist and medical physicist. This information is crucial for compliance.
5. Complete the 'Ownership of Facility/Agency' section by indicating the type of ownership and providing names and addresses as needed.
6. Finally, review your entries in the 'Certification of Understanding' section. Sign and date where indicated to confirm that all information is accurate.

Start using our platform today to streamline your form completion process for free!