Navigating the pathway to becoming a licensed Mammography Radiologic Technologist in Massachusetts involves completing several important steps, one of which includes the Supplemental Application Form. This critical form is designed for individuals who have gained their mammography training and experience outside of Massachusetts and are now seeking licensure within the state. It requires detailed information about one's most recent mammography work, including dates of employment, facility details, and contact information for an immediate supervisor. Applicants must also disclose the number of mammograms they have performed in the last 24 months, along with evidence of their training in mammography, such as letters, certificates of course completion, or CEU certificates. An essential part of this application is the attachment of a notarized copy of the ARRT Mammography Certification. Through the attestation section of the form, applicants declare that all information provided is accurate and true, acknowledging the serious legal consequences of submitting false information. Understanding each section of this form and the importance of accuracy cannot be overstated for those on the path to licensure and the privilege of practicing as a Mammography Radiologic Technologist in Massachusetts.
| Question | Answer |
|---|---|
| Form Name | Supplamental Application Form |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | blank attestation form, experience1, Massachusetts, RADIOLOGIC |
Supplemental Application Form
ATTESTATION REGARDING TRAINING AND EXPERIENCE AS A MAMMOGRAPHY RADIOLOGIC TECHNOLOGIST:
This form must be completed if you are seeking a license as a Massachusetts Mammography Radiologic Technologist through recent mammography training and experience1 outside of Massachusetts. Individuals who are not Massachusetts Radiologic Technology Licensed must complete and submit with this form an Application Form for a Massachusetts Radiologic Technologist License.
I. Most Recent Mammography Experience:
Dates of Employment: from; ________________________to; ___________________________
Facility Name: _________________________________________________________________
Facility Address: _______________________________________________________________
Facility Telephone Number: ________________ Immediate Supervisor: ___________________
II. Number of Mammograms Performed in Past 24 Months: _________________________
III. Training in Mammography:
Dates of Training: ______________________________________________________________
Facility Name: _________________________________________________________________
Facility Address: _______________________________________________________________
Attach written documentation of item II and III above. Acceptable documentation is: a letter, course completion certificate, or CEU certificate.
IV. Attach a notarized copy of your ARRT Mammography Certification.
I, (Please PRINT)_________________________________________, attest that, to the best of my
knowledge and my belief, the information provided in this declaration is true and correct. In addition, I have read and understand the provisions of the Massachusetts Regulations 105 CMR 127.000 Licensing of Mammography Facilities and 125.000 Regulations Governing the Licensing of Radiologic Technologists. I understand that the Commonwealth of Massachusetts may request additional information to substantiate the statements made in this declaration. I also understand that knowingly providing false information could result in criminal liability, punishable by up to $2,000 fine and imprisonment of up to two years, or civil liability under 105 CMR 127.022(E).
______________________________________________________________________________
Attestor's Signature and Title |
Date Signed |