CHANGE OF NAME/ADDRESS FOR RADIOGRAPHY CERTIFICATE 

In order to maintain your certification, you are required to notify this office 
immediately of any name or address changes. Failure to do so may jeopardize your 
certification standing. If requesting name change to your certificate, proof is 
required, e. g. copy of marriage license, judgment of divorce, or court papers. 
Please allow a minimum of three (3) weeks for processing. Incomplete forms will 
be returned. Completed form should be mailed to: 

Delaware Division of Public Health 

Office of Radiation Control 
417 Federal Street 
Dover, DE 19901 

Name on file: __________________________________________________________________

Social Security #: _______________________  Date of Birth:______________________ 

Address on file: _______________________________________________________________ 

________________________________________________________________________________

Change name to: ________________________________________________________________ 

Change address to:  ____________________________________________________________ 

________________________________________________________________________________ 

Phone # 	Home: ______________________________________________________________ 

		Work: ______________________________________________________________ 

Certification #: ______________________Expiration Date: ________________________ 

Signature:___________________________________________Date:______________________ 

Should you have any questions, please feel free to contact the Office of 
Radiation Control at 302-744-4546, or visit our web site at 
http://www.dhss.delaware.gov/dhss/dph/hsp/orc.html 

DELAWARE DIVISION OF PUBLIC HEALTH
OFFICE OF RADIATION CONTROL 
417 FEDERAL STREET
DOVER, DELAWARE 19901