APPLICATION FOR RADIOGRAPHY CERTIFICATE
STATE LIMITED SCOPE MEDICAL, BONE DENSITOMETRY OR DENTAL
FOR DELAWARE RADIATION TECHNICIANS

Please complete and return this application with a non-refundable/non-
transferable application fee toward obtaining a radiography certificate.  
See below for specific examination fees.  Make check or money order 
payable to the State of Delaware and mail to the following address.  
Note that cash will not be accepted, and incomplete applications will be 
returned.  This application will expire six (6) months from the date of 
signature.  Please allow a minimum of three (3) weeks for processing.

Delaware Division of Public Health
Office of Radiation Control
417 Federal Street
Dover, DE  19901
 (PLEASE TYPE OR PRINT LEGIBLY)

NAME:  ________________________________________________	

DAYTIME PHONE: _______________________________________

EVENING PHONE: _______________________________________

ADDRESS: ______________________________________________

________________________________________________________

CITY: ___________________________________________________  

STATE __________________________________________________ 

ZIP:_____________________________________________________

SOCIAL SECURITY NUMBER: ______________________________ 

DATE OF BIRTH:  _________________________________________

============================================================


STATE EXAMINEES (LIMITED SCOPE: MEDICAL RADIATION TECHNICIANS
EXAMINATION FEE:  $110.00 (includes $ 10 application fee) made payable to the 
State of Delaware.
(Your name, address, birth date and social security number will be sent to the 
American Registry of Radiologic Technologists (ARRT) for processing to 
determine exam date).  

I plan to take the following examination(s), (please check all specialties that 
apply):

___Core Medical Exam (required for all),  plus	___ Chest     ___ Extremities   
___ Skull    ___Spine   ___ Podiatry  
					
STATE EXAMINEES: BONE DENSITOMETRY RADIATION TECHNICIANS
EXAMINATION FEE:  $110.00 (includes $ 10 application fee) made payable to the 
State of Delaware.
(Your name, address, birth date and social security number will be sent to the 
American Registry of Radiologic Technologists for processing to determine 
exam date).  

____ Bone Densitometry Operators Exam  (for those seeking to practice bone 
densitometry ONLY)
 
STATE EXAMINEES:  DENTAL RADIATION TECHNICIANS
 ____  Dental Radiation Technician Exam
EXAMINATION FEE:  $10.00 check or money order made payable to the State of 
Delaware.  Upon submitting this form, you will be 
sent a DE Dental Exam application and Factsheet, and the Delaware Radiation 
Technician/Technologist Manual. Upon receiving this packet, 
you will schedule your examination directly with the examination provider 
(DANB).

Are you currently enrolled in a JRCERT* Approved Radiology Program?
	YES_________ NO _________
*JRCERT = Joint Review Committee on Education in Radiologic Technology/Therapy

Are you currently enrolled in a Vocational Dental Assisting Program?  
	YES__________NO__________
If you checked yes, please write in name of your school 
_________________________________________________

Have you been convicted of a felony within the past ten years?  YES_______ NO 
_______  If yes, please explain the circumstances on 
a separate sheet of paper and attach a photocopy of any relevant documentation 
related to how the felony conviction was resolved. 
I certify that the information provided is true to the best of my knowledge.


________________________________________________________________________
                    APPLICANT’S SIGNATURE

DATE

DELAWARE DIVISION OF PUBLIC HEALTH ¨ OFFICE OF RADIATION CONTROL
417 FEDERAL STREET¨ DOVER ¨DELAWARE ¨ 19901
ORC Form R-16-S			35-05-20/08/08/12