ARRA-NIMI Send completed form(s) to:
June 2017
nonionwebform@azrra.gov
ARIZONA RADIATION REGULATORY AGENCY
4814 South 40th Street, Phoenix AZ 85040
Phone (602) 255-4845 Fax (602) 437-0705
https://arra.az.gov
ATTACHMENT TO ARRA-NIR FOR THE REGISTRATION OF NONIONIZING RADIATION DEVICES
(Complete 1 ARRA-NIMI form for EACH unit you are applying to register)
1. Facility Name:
Street Address:
City and Zip:
or NEW Registrant 2. Registration Number for current registrants -
3. Date:
4. Your Name and Title:
5. Machine Type:
Cosmetic Laser Medical Laser Industrial Laser
Cosmetic RF Medical RF Industrial RF
Cosmetic IPL Medical IPL Light Show Laser
Diathermy Electrocautery Dental Laser
Other – Tanning
6. Machine Subtype:
Stationary Mobile Portable Transportable
7. Equipment Information:
Manufacturer name:
Number of heads:
Model Name:
Are you removing this unit from your registration? YES NO
Does this unit replace a previously registered unit in your facility? YES NO
If YES, which one?
If YES, what happened to old unit?
8. SIGNATURE
click to sign
signature
click to edit
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