RENEWAL FOR RADIOGRAPHY CERTIFICATE 

SSN: _______________________________ Date of Birth: ____________________________ 

Name:  _________________________________________________________________________ 

Address:  ______________________________________________________________________ 

City/State/Zip:  _______________________________________________________________ 

Daytime Phone: ________________________ Evening Phone: _________________________ 

If your name has changed, proof is required, e. g. copy of marriage license, 
judgment of divorce, or court papers. Failure to notify this office of 
name/address changes in a timely manner may jeopardize your certification 
standing. 

Individuals certified as ARRT Limited Scope Medical, or those who have passed 
the State Dental Radiation Technician Examination should submit check or money 
order only. 

Individuals holding a National Credential must submit a current photocopy along 
with check or money order; 

		CREDENTIALING		CREDENTIAL		EXPIRATION  
		ORGANIZATION 		ID #			DATE

ARRT 		___________________     ____________________    ________________
NMTCB		___________________     ____________________    ________________ 
DANB		___________________     ____________________    ________________ 
CCI 		___________________     ____________________    ________________

The renewal fee is $50.00, and the check or money order must be made payable to 
the State of Delaware (cash will not be accepted). Please allow a minimum of 
three (3) weeks for processing. Incomplete applications will be returned. 

The completed form should be mailed to the following address: 

Delaware Division of Public Health 
Office of Radiation Control 
417 Federal Street 
Dover, DE 19901 

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. 

Signature:_________________________________Date:_________________________ 

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