ARRA-4 https://arra.az.gov Phone (602) 255-4845
June 2017 4814 S. 40 email@example.com
St. Phoenix, AZ. 85040.
ARIZONA RADIATION REGULATORY AGENCY
APPLICATION FOR REGISTERING X-RAY RADIATION DEVICES
Check appropriate selection and provide registration number if currently registered.
(name, address, and/or ownership changes)
For renewals and amendments,
provide registration number here.
location where devices
Or check box if same as:
Billing Address: Or
check box if same as:
Check Type of X-ray Facility
Must Submit ARRA-ET)
Legal Structure of Applicant – Check one and provide the required information
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. https://arra.az.gov/xray-facility/x-ray-faq.
(e.g. LLC, Non-profit,
Provide your Arizona Corporation
Commission File Number
You are required to submit an attachment to this application listing the name and address of each
individual or legal entity owning a partnership interest and the percent ownership held by each.
City, County, or
Business name of applicant above must clearly identify the government entity.
For questions regarding X- ray registration, please visit the X-ray section of www.arra.az.gov. New Registrants will also find
there a downloadable fee schedule. Please make check or money order payable to Arizona Radiation Regulatory Agency or
The applicant or any official executing this application on behalf of the applicant certifies that this
application has been prepared in accordance with Arizona Administrative Code, Title 12, Chapter 1,
and all information contained on this application, including any supplements and attachments, is true
and correct to the best of his or her knowledge and belief.
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.
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.
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.
This section does not abrogate the immunity provided by section 12-820.01 or 12-820.02.