Form Cdph 8232 PDF Details

Form cdph 8232 is a document used to request a change in the name of an entity regulated by the California Department of Public Health (CDPH). This form can be used to request a name change for a business, nonprofit organization, or other type of entity regulated by CDPH. The process for requesting a name change using this form is relatively simple, and can be completed in just a few minutes. In order to submit a request for a name change, you will need to provide some basic information about your entity, including its current name and the new name you would like to use. You will also need to provide contact information for the individual or organization responsible for submitting the request. Once you have filled out the form, you can submit it online or mail it in to CDPH. Note that there may be some restrictions on what names are allowed, so be sure to check with CDPH before submitting your request.

QuestionAnswer
Form NameForm Cdph 8232
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesureters, Radiologic, X-Ray, cdph radiologic health branch

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State of California—Health and Human Services Agency

California Department of Public Health

 

Radiologic Health Branch

X-Ray Technician Limited Permit Application

(Failure to use your full legal name may result in entrance into the examination being denied.)

Last Name (Please Print)

First Name

Middle Name

 

 

 

 

 

Date of Birth

Social Security Number

Phone Number

 

 

 

 

Mailing Address

 

E-mail Address

 

 

 

 

 

City

 

State

 

Zip Code

 

 

 

 

 

Pursuant to the authority found in Section 114870 of the California Health and Safety Code and as required by Section 17520 of the California Family Code, providing the social security number is mandatory. The social security number will be used for purposes of identification. The information on this form may be provided to federal, state, or local agencies for law enforcement purposes. This information may also be provided to the American Registry of Radiologic Technologists for examination purposes. For information or access to your records, contact the Registration and Certification Support Unit at the California Department of Public Health, Radiologic Health Branch (CDPH-RHB), MS 7610, P.O. Box 997414, Sacramento, CA 95899-7414, (916) 327-5106.

HOW DO I OBTAIN A CALIFORNIA X-RAY TECHNICIAN LIMITED PERMIT?

1)You must check the box below for each permit category for which you are applying:

PLEASE NOTE: You must submit all supporting documents and the payment for the non- refundable application fee of $75.00, for each category selected.

Chest radiography permit: radiography of the heart and lungs.

Extremities radiography permit: radiography of the upper extremities, including shoulder girdle, and lower extremities, excluding pelvis.

Leg-podiatric radiography permit: radiography of the knee, tibia and fibula, and ankle and foot.

Skull radiography permit: radiography of the bone and soft tissues of the skull and upper neck.

Torso-skeletal radiography permit: radiography of the shoulder girdle, rib cage and sternum, vertebral column, pelvis and hip joints.

Dental laboratory radiography permit: radiography of the intra-oral cavity, skull, hand and wrist, for dental purposes.

IMPORTANT: Do not submit this form for an X-ray Technician Bone Densitometry Permit. Instead, use form CDPH 8232 BD, X-Ray Technician Bone Densitometry Permit Application.

2)You must take and pass an examination for each permit category selected, provided you meet the requirements to sit for the examination. You must return this application along with the following:

A copy of your limited permit X-ray technician school graduation diploma or certificate in the limited permit category(ies) applied for, and

The non-refundable application fee of $75.00 for each category applied for in the form of a check (e.g., personal, cashier’s, or certified check) or money order made payable to CDPH-RHB.

CDPH 8232 (10/13)

Page 1 of 2

State of California—Health and Human Services Agency

California Department of Public Health

 

Radiologic Health Branch

X-Ray Technician Limited Permit Application

(Failure to use your full legal name may result in entrance into the examination being denied.)

Last Name (Please Print)

First Name

Middle Name

HOW WILL I BE NOTIFIED ABOUT THE STATUS OF MY APPLICATION?

Within 30 calendar days of receipt of your application, CDPH-RHB will mail you a notification letter. The notification letter will inform you of one of the following:

•That your application is acceptable and what examination you must pass within 1 calendar year in order to obtain the certificate/permit, and instructions on how to submit payment of the non-refundable examination fee; or

•That your application is not accepted for filing and what specific information, documentation or fee you must submit within 30 calendar days in order for CDPH-RHB to consider the application acceptable.

CAN I TAKE MORE THAN ONE EXAMINATION ON THE SAME DATE?

Yes! You can take chest, extremities, skull, torso-skeletal, and/or leg-podiatric radiography examinations together on the same date for the cost of one examination fee. If you applied for a Dental laboratory radiography permit, you will not be able to take the examination along with the examination for any other categories on the same date. Remember to include a copy of your limited permit X-ray technician school graduation diploma or certificate for each limited permit category applied for, and the non-refundable application fee of $75.00 for each category applied for in the form of a check (e.g., personal, cashier’s, or certified check) or money order made payable to CDPH-RHB.

HOW DO I SUBMIT MY APPLICATION?

Please mail this application, all supporting documents, and payment for the non-refundable application fee of $75.00 for each category to:

California Department of Public Health

Radiologic Health Branch, MS 7610

Accounts Receivable and Cashiering Unit

P.O. Box 997414

Sacramento, CA 95899-7414

I certify that the information provided with this application is true and correct. I understand that the California Department of Public Health may revoke permits that are procured by fraud, misrepresentation, or mistake, or for the nonpayment of fees. Further, I am aware that it is unlawful to use X-rays on human beings in this state unless I have been granted a permit pursuant to the Radiologic Technology Act, acting within the scope of that permit, and acting under the supervision of a licentiate of the healing arts who is a certified supervisor or operator.

Signature

Date

CDPH 8232 (10/13)

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