ARRA-NIR www.azdhs.gov
March 2019 4814 South 40
th
St. Phoenix, AZ. 85040.
Phone (602) 255-4845
nonion@azdhs.gov
ARIZONA DEPARTMENT OF HEALTH SERVICES
BUREAU OF RADIATION CONTOL
APPLICATION FOR REGISTERING NONIONIZING RADIATION DEVICES
Check appropriate selection and provide your registration number if currently registered with the agency.
New
Registrant
Registration Renewal
Registration Amendment
(name, address, and/or ownership changes)
For renewals and amendments, provide _
your registration number here
Legal Business Name:
DBA if
different
Physical Address:
location where
devices are utilized
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Mailing Address:
Or check box if same as:
Physical Address
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Billing Address: Or check
box if same as:
Physical Address
Or
Mailing Address
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Contact Name Contact’s Title
Phone No. Fax No. Email
Indicate Type of Nonionizing Facility
Tanning
Laser Radio Frequency
Indicate laser sub-type below Indicate RF sub-type below
Cosmetic Industrial Light Show Medical Dental Industrial Medical
Legal Structure of Applicant – Check one and provide the required information
Individual or
Sole Proprietorship
ARS § 41-1080 requires applicants in this classification to submit documentation of citizenship or
alien status by presenting an AZ driver’s license issued after 1996 or another acceptable form of
identification. Acceptable forms of documentation
Any Corporation (e.g.
LLC, Non-profit, S-Corp.,
P.C.)
Provide your Arizona Corporation
Commission File Number
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Partnership
You are required to submit an attachment to this application listi
ng the name and address of each
individual or legal entity owning a partnership interest and the percent ownership held by each.
City, County, or State
Government
Business name of applicant above must clearly identify the government entity.
Please make checks or money orders payable to Arizona Department of Health Services or AZDHS
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A.R.S. §41-1030. Invalidity of rules not made according to this chapter; prohibited agency action; prohibited acts by state employees;
enforcement; notice
B. An agency shall not base a licensing decision in whole or in part on a licensing requirement or condition that is not specifically authorized by statute,
rule or state tribal gaming compact. A general grant of authority in statute does not constitute a basis for imposing a licensing requirement or
condition unless a rule is made pursuant to that general grant of authority that specifically authorizes the requirement or condition.
D. This section may be enforced in a private civil action and relief may be awarded against the state. The court may award reasonable attorney fees,
damages and all fees associated with the license application to a party that prevails in an action against the state for a violation of this section.
E.
A state employee may not intentionally or knowingly violate this section. A violation of this section is cause for disciplinary action or dismissal
pursuant to the Agency's adopted personnel policy.
F. This section does not abrogate the immunity provided by section 12-820.01 or 12-820.02.
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