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PO BOX 144103 2026
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- Click ‘Get Form’ to open the PO BOX 144103 document in the editor.
- 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.
- 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.
- In the 'Staff Information' section, input the license numbers for both the radiology technologist and medical physicist. This information is crucial for compliance.
- Complete the 'Ownership of Facility/Agency' section by indicating the type of ownership and providing names and addresses as needed.
- Finally, review your entries in the 'Certification of Understanding' section. Sign and date where indicated to confirm that all information is accurate.
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See more PO BOX 144103 versions
We've got more versions of the PO BOX 144103 form. Select the right PO BOX 144103 version from the list and start editing it straight away!
| Versions | Form popularity | Fillable & printable |
|---|---|---|
| 2016 | 4.8 Satisfied (49 Votes) |
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Related links
Division of Licensing and Background Checks, Office of Background Processing, PO Box 144103, Salt Lake City, UT 84114. Department of Health and Human Services,
Apr 24, 2013 Comprehensive Environmental Response, Compensa- tion, and Liability. COMPREHENSIVE ENVIRON- MENTAL RESPONSE, COMPENSATION, AND LIABILITY ACT.
Utah Bureau of Health Facility Licensing and Certification PO Box 144103 Salt Lake City, Utah 84114