Forms

GENERAL AGENCY FORMS

• Services Registration Application (ARRA-SRA)
• Physicist Support Application - Physics Support in variety of modalities (does not add to license or registration)
• NVLAP Approved Dosimetry Services
• Radiation Safety Consultants - Registered Physics Support
• ARRA Complaint Form
• Request for Public Documents - Commercial Use
• Request for Public Documents - Non-Commercial Use

NONIONIZING APPLICATIONS

• Non-Ionizing Facility Registration (ARRA-NIR)- Nonionizing Radiation Facility
• Non-Ionizing Machine Information (ARRA-NIMI) - Make and Model name of each Bed, Laser, RF, etc.
• Medical Director/Prescribing Official Attestation/ApplicationPrescribing Authority ONLY
• Health Professional Training Application/AttestationRegistered Nurses and Physician's Assistants (RN's & PA's)
• Medical Director Acknowledgement (Non-Cosmetic) form for Medical Facilities (Hospitals, Medical Offices, Veterinary Offices, Podiatric, and Dental Offices) 
• Medical Director Acknowledgement (Chiro) Medical Director Acknowledgement/liability for Chiropratic Offices
• Cosmetic Facility Medical Director Acknowledgement form for IPL/Laser Hair Removal and Cosmetic Facilities
• LSO Acknowledgement Statement form for Laser Safety Officers
• RF Acknowledgment Form Acknowledgment form for individuals in charge of RadioFrequency Safety
• Nonionizing Annual and Registration Fee Schedule

LASER TECHNICIAN FORMS

• New Laser Technician Application
• Laser Technician Renewal Application
• Affidavit of Practice - Cosmetic Laser Tech
• Affidavit of Non Practice - Cosmetic Laser Tech
• CLT Duplicate Certificate Request Form
• New Cosmetic Training School Application and Renewal- Application for Didactic and Hands-on Training Schools
• Supervising Laser Technician (SLT) 24 hr Approval letter
• Supervising Prescribing Health Professional 24 hr approval letter (Medical Director)
• Supervising Health Professional 24 hr approval letter 

MRTBE FORMS

• MRTBE application for all 
• MRTBE-CT-Preceptorship Training Application 
• PTR Acknowledgment - Scope of Practice for PTR, PTP, PTBD
• MRTBE Blank Renewal Form
• Mammography Student Form 
• Radiologist Assistant Application 
• AccuBoost Positioning Verification form 
• Affidavit of Practice 
• Affidavit of non Practice 
• MRTBE Complaint form
• Application for Boards and Commissions- Application to serve as a MRTBE Board Member

X-RAY APPLICATIONS

• X-Ray Facility Application (ARRA-4) - Application for Registration of X-Ray Facility
• X-Ray Annual and Registration Fee Schedule X-Ray unit (by Tube and intended use)
• Industrial Unit Information (ARRA-4I) - Supplimental for Industrial or Medical specimen unit
• Medical Unit Information (ARRA-4X) - Supplimental for Medical/Dental/Veterinary 
• Mammography Screening Application (ARRA-13)- Supplimental Application for Screening Approval
• E-Brachytherapy Supplimental Application (ARRA-ET) - Therapy Supplemental Form

RAM APPLICATIONS

• Industrial/Medical Specific Materials License (ARRA-1G)
• Legal Structure Cover Application (AZRRA-LSRAM) for the Radioactive Materials Program
• Laboratory-Industrial License Application (ARRA-L)
• Small Entity form
• Authorized Medical Physicist Preceptor
• Authorized Nuclear Pharmacist Preceptor 
• Authorized User Preceptor(100,200,& 500) 
• Authorized User Preceptor(300) 
• Authorized User Preceptor(400 & 600)
• Radiation Safety Officer Preceptor (ARRA-2) 
• Depleted Uranium Application (ARRA-23)
• Fixed Gauge Application (ARRA-FG)
• Industrial Radiography Application (ARRA-IR)
• Medical Application (ARRA-M)
• Medical Event Reporting Form (ARRA-ME)
• Particle Accelerator Application (ARRA-PA)
• Portable Gauge Application (ARRA-1PG)
• Reciprocity Application (ARRA-REC)
• Radiation Safety Officer (Delegation of Authority) 
• Registration Certificate Gauging Device with Radioactive Material Under General License (ARRA-17)

* All forms/applications are in Adobe PDF format. Click icon to get Adobe Acrobat Reader.