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Application (For Office Use Only)

Department of Environmental Quality

Date Received: _____________

Office of Environmental Compliance

Licensing & Registrations Section

Date Scanned: ______________

P.O. Box 4312

User Group: ____Radiation____

Baton Rouge, LA 70821-4312

AI#: ______________________

Phone: (225) 219-3041 Fax: (225) 219-3154

Application for Industrial Radiography Certification

Form DRC 20 (rev 12/3/14)

(Check all boxes that apply)

[](1) New Application for Exam

[](6) Application for Trainee

[](8) Request for Change of Information /

Exam Date:_________________________(2)

Status

ie, expiration date, change of company name, etc.

Minimum Requirements:

Exam Type: [] Initial [] Re-Exam [] Renewal

(1) 40 Hour Course

[](9) Are you a Certified Radiographer or Trainee?

⁭ Yes

⁭ No

(3)

(2) 40 Hours of on-the-job

If “yes” provide Card/Certification ID#___________

training

Exam Category: [] RAM [] X-Ray [] Both

[](7) Replacement Card ($26)

[](10) Has your Card/Certification ever been

(4)

[] Trainee Card

revoked, suspended or is currently under a

violation review? ⁭ Yes

⁭ No

[](5) Application for Certified Radiographer Status

[] State Card

If “yes” explain on separate sheet.

Note: The fee of $178.00 must be made payable to DEQ and must be included with this application for examination processing. (Check or money order only)

___________________

____________________________________________________________________(11)

(12)

Applicant’s Full Name (Last, First, Middle)

State of Issuance, Complete Driver License Number

___________________________________________________________________________(13)

____________________________(14)

Residence Address (Number, Street, City, State, Zip)

Date of Birth (mm/dd/yy)

_____________________________________

(15)

Email address:_________________________________(16)

Residence Telephone Number

Certification Card Number:___________________________________(17)

State:_______________(18)

Expiration Date:______________________(19)

__________________________________________________________________________________________________________________________________________

Company Information

Present Employer:____________________________________(20) Agency Interest ID No.:_______________

License/Registration No:____________________ (21)

Optional

RSO/Contact:____________________________________________

Start Date:_____________(22) End Date:________________(23)

(24)

____________________________________________

Phone Number:_______________________________________(25)

Email address:

(26)

_____________________________________________________________________________________________________________________________________

Training Information

The above individual has been instructed for at least 40 hours in the subjects outlined in sections I, II, and III in Appendix A of Chapter 5 of the

Louisiana Radiation Protection Regulations (LAC 33:XV). Both the instructor and the course of instruction were approved by the Department prior to

the time of instruction. A copy of the training course certificate is required if Trainee Status is requested or if applying for initial exam.

Firm, School, or Consultant:__________________________________

Dates of Instruction:_________________________________________

(27)

(28)

(“on file” or “previously submitted” is not acceptable):

The above individual has received the following total hours of on-the-job training (OJT)

______

Radioactive Material OJT

________

X-Ray OJT

Dates of Training:_______________________________________

(29)

(30)

(31)

( hours)

(hours)

Name of instructor: ______________________________________

Signature of Instructor:___________________________________

(32)

(33)

[]

The above individual has received instruction and passed a company-specific written exam and field test on the company’s operating and

(34)

emergency procedures.

Please Note:

Trainee status will only be granted for a period not to exceed five years.

Trainees must work under the personal supervision of an instructor who is specified on the company license.

Trainee status is not valid until a confirmation letter and card are received from the Department.

The Trainee Status authorization card received from the Department must be kept with the trainee at all times during industrial radiography

operations.

I hereby certify that the information I have provided is true and correct to the best of my knowledge.

_________________________________________(35) _________________(36)

____________________________________(37) _________________(38)

Signature of RSO/Company Representative

Date

Signature of Applicant (if applicable)

Date

Note: A new DRC-20 Form is required to be completed on each radiographer employed by your company, even if a form has been completed by a previous employer.

Form Drc 20 - Application For Industrial Radiography Certification - Louisiana Department Of Environmental Quality

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