DELAWARE HEALTH AND SOCIAL SERVICES Division of Public Health Office of Radiation Control APPLICATION FOR REGISTRATION OF A NEW RADIATION SERVICE PROVIDER PLEASE READ ATTACHED INSTRUCTIONS PRIOR TO COMPLETING 1. COMPANY OR INDIVIDUAL (if sole proprietorship) Name: __________________________________________________________________________ Address: _______________________________________________________________________ City: _________________ State: ______ Zip:_______ Phone Number: _______________ EIN/Social Security No. ______________________________ Fax Number: _____________ a. NAME OF RSO OR REGULATORY AFFAIRS OFFICER____________________________________ 2. AREA FOR WHICH REGISTRATION IS BEING APPLIED: (Check all that apply) ()(a) Installation and/or servicing of radiation machines and associated machine components; ()(b) Calibration of radiation machines or radiation measurement instruments or devices; ()(c) Radiation protection or health physics consultations or surveys; (attach resume) ()(d) Personnel dosimeter services; ()(e) Radiation shielding per NCRP Report #49; ()(f) Radiation Therapy Physicist operating therapeutic radiation machine (attach resume) 3. CERTIFICATIONS HELD: ____________________ __________________ ______________________________________ TITLE ID # NAME OF HOLDER ____________________ __________________ ______________________________________ TITLE ID # NAME OF HOLDER ____________________ __________________ ______________________________________ TITLE ID # NAME OF HOLDER 4. TRAINING OF APPLICANT: (attach supporting documentation) a. FORMAL EDUCATION BACKGROUND: Academic Degree School Major Year _____________________ ______________________ ________________ ______________ _____________________ ______________________ ________________ ______________ _____________________ ______________________ ________________ ______________ b. SPECIFIC TRAINING OR BOARD CERTIFICATION IN THE AREA OF REGISTRATION APPLIED FOR: (attach supporting documentation) Course Title Location Dates Nature of Training ____________________________ ________________ __________ ____________________ ____________________________ ________________ __________ ____________________ ____________________________ ________________ __________ ____________________ 5. EXPERIENCE OF APPLICANT: (attach supporting documentation) a. LIST RELEVANT EMPLOYMENT HISTORY: Organization Position Dates % of Time ____________________________ ______________________ __________ ______________ ____________________________ ______________________ __________ ______________ ____________________________ ______________________ __________ ______________ b. LIST UP TO THREE (3) FACILITIES YOU PLAN TO SERVICE IN DELAWARE: ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ 6. I certify that I have read and understand Parts A & B of the Delaware Radiation Control Regulations, and that the information submitted is true to the best of my knowledge. SIGNATURE: ___________________________________________________ DATE: __________ TYPE OR PRINT NAME: ____________________________________________________________________ In order to facilitate processing, please be sure that all items on the application have been completed before sending to the agency. Incomplete applications will be returned. Please allow a minimum of (3) weeks for processing. This form may be photocopied, and applicants should retain a copy for their records. If you have any questions, please contact the Office of Radiation Control at 302-744-4546. To download forms or obtain a copy of the regulations, please visit our web site at http://www.dhss.delaware.gov/dhss/dph/hsp/orc.html. Mail completed application form to: Delaware Division of Public Health Office of Radiation Control 417 Federal Street Dover, DE 19901 INSTRUCTIONS FOR APPLICATION FORM ORC - R3 ITEM INSTRUCTIONS AND DEFINITIONS 1. COMPANY AND/OR INDIVIDUAL - Enter complete company name, owner/manager, or individual name if sole proprietorship, mailing address, EIN or SS #, telephone number and fax number. 2. AREA FOR WHICH REGISTRATION IS BEING APPLIED - Check the appropriate item(s), a-f. For Area C, attach resume for Principal Consultant of firm. For area F, attach resume for Physicist(s). 3. CERTIFICATIONS HELD - Enter the title, ID number of relevant certification(s), name of Owner, and supporting documentation. If held by an employee, note by "E"; if held by owner/manager, note by "C". 4. TRAINING OF APPLICANT OR EMPLOYEE - Enter the required information regarding the formal education background of the Owner/Manager, note by "C"; if held by an employee, note by "E". List training related to the area of which registration is applied. Under "Nature of Training", indicate "on-the-job", "formal.” Do not list more than three (3) employees. Where work is performed by more than three (3) employees, briefly describe company minimum for radiation equipment and safety training held by employees. 5. EXPERIENCE OF APPLICANT (Do not list more than three (3) employees, see four (4) above) - Enter relevant employment history. Under "% of time", show the actual percentage of the work week that was spent on relevant tasks. 5b. DELAWARE CUSTOMERS - List three (3) facilities you plan to service in the State of Delaware. 6. SIGNATURE OF APPLICANT - A general knowledge and understanding of Parts A & B of the Delaware Radiation Control Regulations (DRCR), under which all Radiation Service Companies must operate in Delaware, is the responsibility of the Owner/Manager. The application form must be signed by the Company Owner/Manager or individual if sole proprietorship. The registration is not valid until a “Notice of Registration” has been issued, a copy will be mailed to the applicant. Doc. No. 35-05-20/08/07/12