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RENEWAL APPLICATION

VIEWS: 175 PAGES: 2

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State of New Mexico

ENVIRONMENT DEPARTMENT
Radiation Control Bureau Radiologic Technologist Program P.O. Box 26110 Santa Fe, New Mexico 87502-6110 Telephone (505) 476-3264 Fax (505) 476-3015
http://www.nmenv.state.nm.us/nmrcb/radtech.html

BILL RICHARDSON GOVERNOR

RON CURRY SECRETARY

NEW APPLICATION
SOCIAL SECURITY #: _____________________________________________ Date of Birth: ______/______/_______ APPLICANT’S FULL NAME & ADDRESS: (Unless otherwise indicated, certificate will be mailed to this address.) _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ Home Phone (_____) _______-________________ Cell Phone (_____) ________-________________ Email: ___________________________________

New Mexico regulations require that original Certificates be prominently displayed at EACH place of employment. List ALL New Mexico facilities where certificates will be displayed. Include FACILITY’S PHYSICAL ADDRESS and PHONE NUMBER .
1. ________________________________________________________________________________________________________(_____)_______-__________ 2. ________________________________________________________________________________________________________(_____)_______-__________ 3. ________________________________________________________________________________________________________(_____)_______-__________

FEE SCHEDULE - Please check all that apply:
______ TEMORARY CERTIFICATION $35.00 (Includes a $10.00 application fee) NOTE: The Department may issue a temporary certificate to practice as a radiologic technologist to a person who satisfactorily completes an approved educational program in radiologic technology and who is awaiting results of the radiologic technology exam. Temporary certificates must be applied for within one year of graduation date, expires one year from graduation date or immediately upon notification of failure of state or ARRT exam and are issued only once and CANNOT be renewed or extended. Applicants must submit copies of graduation certificate, diplomas or transcripts indicating the successful completion date. Applicants successfully passing the radiologic technologist examination must apply for full or limited certification 60(sixty) calendar days prior to the expiration of their temporary certificate. FULL CERTIFICATE $110.00 (Includes a $10.00 application fee) NOTE: send copy of current ARRT or NMTCB card. _______ Radiography (RRT) ________ Radiation Therapy (RTT) ________ Nuclear Medicine (NMT) ______ Duplicate of an Original Certificate - $15.00 for the first duplicate and $5.00 each additional duplicate Original Certificate. ______ Replacement of Certificate with Name Change $15.00 (Must include copy of official name change documentation.) CERTIFICATE of LIMITED PRACTICE $60.00 ___Axial /Appendicular Skeleton ___Extremities ___Foot, Ankle & Lower Leg ___Viscera of the Thorax
I HERBY CERTIFY THAT I HAVE NOT BEEN CONVICTED OF A FELONY AND I AM NOT DELINQUENT ON CHILD SUPPORT* AND THAT ALL THE INFORMATION PROVIDED IS TRUE TO THE BEST OF MY KNOWLEDGE.

Signature: _______________________________________________________ Date: ________________________ Check or Money Order # ______________________________ Amount _________________________________.

Please make checks payable to the “Radiologic Technologist Fund”. Please do not send cash.
*The Parental Responsibility Act (July 1995) requires New Mexico Environment Department (NMED) to revoke all certificates of individuals who are not in compliance with this act.

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PLEASE SUBMIT THE FOLLOWING WITH YOUR APPLICATION:

Submit copies of documents stating current membership of a nationally recognized certifying organization, i.e., the ARRT, the ACRRT, or NMTCB. Submit current copies of current wallet cards or certificates that show expiration date. Please include a copy of an identification card such as a driver’s license or passport. Please include a written letter that states the following information: education background, medical radiography education and training, medically related professional affiliation, certificates and licenses from other states, medically related work experience and proposed certification and Radiologic technology specialty. Note: Send only copies of documents, because materials submitted with packet will not be returned. The successful completion of a State examination is required by the NMED regulations. Contact this office for an exam application. TEMPORARY CERTIFICATION is a one-time certification ONLY and expires upon failure to pass state examination within the allotted time period.

CONTINUING EDUCATION:
Once a new full or limited certificate is issued a minimum of twenty Category “A” Continuing Education Units (CEU’s) are needed for each biennial period. Two of the twenty CEU’s must be of the subject of Radiation and Protection. The biennial period begins twenty-four months prior to the expiration date that is located on applicants current certificate. Only CEU’s that are within that biennial period will be accepted. Renewals will NOT be processed until all attendance certificates are accounted for and all fees have been paid in full.

Regular Mailing Address: Radiation Protection Program, Attention: Stephen M. Sanchez, P.O. Box 26110, Santa Fe, NM 87502-6110. All certificates will be processed and mailed using regular First Class U.S. Mail. In order to expedite the application process, applications may be sent by other express delivery carriers. The physical street address for use by those types of carriers is: Radiation Protection Program, Attention: Stephen M. Sanchez, 1190 ST. FRANCIS DRIVE – ROOM S. 2100, Santa Fe, NM 87505. Questions, please call (505) 476-3264.

Express Service:

Applications will be processed in the order received. However, if a completed returned pre-paid air bill or postage paid return envelope is sent within the application package, the renewal certificate, upon proper approval, will be processed first and sent to the applicant. Otherwise, First Class U.S. Mail will be used.
DO NOT FAX APPLICATIONS. ORIGINAL CERTIFICATES MUST BE PROMINENTLY DISPLAYED AT EACH PLACE OF EMPLOYMENT BEFORE BEGINNING EMPLOYMENT.
Signature: _______________________________________________________ Date: ________________________

Please sign, date and return this page with the application packet.

Form revised 2/5/04.
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