Form Cdph 8435 Sra – Fill Out and Use This PDF

State of California—Health and Human Services Agency	California Department of Public Health
	Radiologic Health Branch

Please Do Not use this Renewal Application if your certificate expires on or after

January 31, 2015 due to fee increase

*SPECIAL RENEWAL APPLICATION

* This form is for use only by those who did not receive their renewal billing notice 45 days before their expiration date.

California Nuclear Medicine Technology Certificate

Number of Scopes Issued	Certificate Number	Certificate Expiration Date
Last Name, suffix	First Name	Middle Name

Mailing Address Check this box if this is a change of address since your last certificate/permit was issued.

City

It is very important that you provide your full true name.

Return this form along with your applicable nonrefundable renewal fee payment in the form of a check

or money order made payable to “CDPH-RHB” (California Department of Public Health – Radiologic Health Branch) for:

$175.00 if your certificate has not expired.

$218.75 if your certificate has expired.

Attach documentation that establishes your participation in management sponsored or formal continuing education offered by professional organizations or societies or institutions of higher learning. This education and training is required to be of at least five clock hours in each of the scopes for which your certificate was issued since your last certificate renewal or initial application.

Include your nonrefundable fee payment with attachments and mail this form to:

Billing and Cashiering Unit

California Department of Public Health

Radiologic Health Branch

MS 7610

P.O. Box 997414

Sacramento, CA 95899-7414

I certify that all information provided with this application is true and correct. I understand that the California Department of Public Health may cancel certificates that are procured by fraud, misrepresentation, or mistake, and may revoke certificates 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 am certified pursuant to the Radiologic Technology Act, I am acting within the scope of that certification, and I am acting under the supervision of a licentiate of the healing arts who is a certified supervisor or operator.

CDPH 8435 SRA (10/14)

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