Form 27068 - Application For Radiology License Or Permit - Indiana State Department Of Health
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1
2APPLICATION FOR RADIOLOGY
LICENSE OR PERMIT
State Form 27068 (R13/3-07)
Approved by State Board of Accounts, 2007
INSTRUCTIONS:
1. Fill out all blocks. This application will be returned to you without processing if any information is missing. If an item does not apply
put “NA” in that block. Do not use abbreviations in any area on the application.
2. Type or clearly print all information.
3. Make a personal check or money order for $60 payable to: Indiana State Department of Health. (No fee is required for student or
provisional permits.)
P.O.
4. Send the completed form and fee to: Indiana State Department of Health, ATTN: Cashier’s Offices,
Box 7236, Indianapolis, IN 46207-7236
.
5. You will receive your certificate from the Division of Medical Radiology Services or a letter
indicating why your application was rejected.
6. If you have any questions, call AC 317/233-7565 Division of Medical Radiology Services or e-mail radiology@isdh.in.gov.
7. The disclosure of your Social Security Number is required in accordance with IC 4-1-8-1.
Applicant Information:
Last Name:
First Name:
MI:
Home Address
(number, street, P. O. Box):
City:
State:
9 Digit Zip Code:
Social Security Number:
Home Phone Number: (Including area code)
Date of Birth
: (mm/dd/yyyy)
(
)
Category of Permit or License:
Select one category of Permit or License (check one box only)
PERMIT:
Student Radiography
Student Nuclear Medicine
Provisional Radiography
Student Radiation Therapy
Student Dental Radiography
LICENSE:
Limited Chest
Limited Dental
Limited Podiatric
Limited Chiropractic
Limited Cardiac Catheterization
Radiation Therapy
Radiologic Technologist
Nuclear Medicine Technologist
High School Education Information
High school:
_______________________
Have you graduated from high
If G.E.D., give number and
school? If yes, indicate the date:
date:
Location:___________________________
Yes
or
No
____/____/____
(mm / dd /yyyy)
Approved Educational Program:
Name of School:
Location of School:
Date Enrolled
Date Graduated or
(mm/dd/yyyy):
Projected to Graduate:
(mm/dd/yyyy)
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