please attach a copy of the hardship exemption letter and also provide the following by 0YxjB6I8

VIEWS: 5 PAGES: 1

									                                               Texas Medical Board
                                      Mailing Address: PO Box 2029, MC-241-C, Austin, Texas 78768-2029
                                                            Phone: (512) 305-7025

                    NON-CERTIFIED RADIOLOGIC TECHNICIAN APPLICATION
                                           TE
PLEASE PRINT IN INK OR TYPE
ATTACH CHECK OR MONEY ORDER FOR $52.00
FEE IS NON-REFUNDABLE AND NON-TRANSFERRABLE

RETURN TO: TEXAS MEDICAL BOARD, MC-241-C, PO BOX 2029, AUSTIN, TX 78768-2029

NAME:      _______________________________________________________________________________________________________________________________
                   LAST                                 FIRST                                MIDDLE


MAILING ADDRESS: ______________________________________________________________________________________________________________
                                        NUMBER              STREET                                APT/SUITE #


                                        CITY                                   STATE              ZIP


ADDRESS OF EMPLOYMENT: _________________________________________________________________________________________________
    (Physical Address; No PO Boxes)              NUMBER                        STREET             APT/SUITE #


                                                 CITY                          STATE              ZIP

DATE OF BIRTH: _________________________                  SOCIAL SECURITY NUMBER: ___________________________________
                               MONTH/DAY/YEAR


Are you currently on the registry with the Texas Department of State Health Services? (Circle) YES                     NO
If yes, please attach a copy of the letter showing your current status on the registry and also provide the following:

                                                                     Expiration Date: __________________________

Has your employer received a hardship exemption from the Texas Department of State Health Services?
                                                                                              (Circle) YES                              NO
If yes, please attach a copy of the hardship exemption letter and also provide the following:

                                                                     Expiration Date: ___________________________

NOTE: You must either be on the NCT registry with the Texas Department of State Health Services or your employer must have a
hardship exemption from the Texas Department of State Health Services. You must include a copy of one of these documents. A
permit will not be issued without one of these documents.

I certify that the information which I have provided on this application is correct and further, I
understand that if this application has not been completed in every detail, the board is not authorized
to issue my permit.

Date                           Signature
                                                 SIGNATURE OF NON-CERTIFIED RADIOLOGIC TECHNICIAN (No Stamped, Photocopied or Faxed Signatures)




(For Agency Use Only ) ID#:___________________________________________                                               Form Revised 01/12/2006
                             Location Address: 333 GUADALUPE • TOWER 3 • SUITE 610 • AUSTIN TX 78701
                                                    WEB SITE ADDRESS: www.tmb.state.tx.us

								
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