APPLICATION FOR RADIOGRAPHY CERTIFICATE
RECOGNITION OF NATIONAL CREDENTIAL

Please complete and return this application with a non-refundable/non-transferable application fee of $10.00 toward 
obtaining a radiography certificate.  Make check or money order payable to the State of Delaware, and mail to the 
following address.  Note that cash will not be accepted.  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:  _________________
=======================================================================================
APPLYING FOR DELAWARE RADIOGRAPHY CERTIFICATE TO PRACTICE:  
_____  CARDIOVASCULAR
_____  COMPUTED TOMOGRAPHY (CT)	 
_____  MEDICAL RADIOGRAPHY (X-RAY)            
_____  NUCLEAR MEDICINE	
_____  RADIATION THERAPY     
_____  DENTAL

I hold national credential(s) from:  ___ARRT    	 ____NMTCB     	____CCI	____ DANB
(please check all that apply)

CARD NUMBER: ____________________________  PROOF IS REQUIRED FOR EACH CREDENTIAL.
PHOTOCOPY ENCLOSED:	____MEMBERSHIP CARD        

OR,

I am scheduled to take a national credentialing board examination on __________________________(date).  
PHOTOCOPY ENCLOSED:	____Exam reservation 	____Processing Status Report	 (Check one) 

I have included a $10.00 check or money order made payable to the State of Delaware:   ____Yes   ____No

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.  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, DE  19901

ORC Form R-16-N			35-05-20/07/09/01