State of California—Health and Human Services Agency California Department of Public Health
Radiologic Health Branch
SPECIAL RENEWAL APPLICATION
California Radiologic Technology Certificate
Certificate Number Certificate Expiration Date Phone Number
Last Name, Suffix First Name Middle Name
Social Security Number / ITIN Date of Birth (MM/DD/YYYY)
Email Address
Mailing Address or P.O. Box Number Check if you are requesting to change your address
City State Zip Code
Name change requests must be accompanied by a copy of a certified superior court order allowing the name change and a
government issued picture ID, such as a driver’s license, military ID, or passport. The information you provide on this form
(except Social Security Numbers and Date of Birth) may be made public by the California Public Records Act; please provide a
P.O. Box number or other alternate address and/or an alternate phone number if you do not wish to have your home address
and/or phone number made public.
Please list the required 24 credits in the space provided below, accordingly. Complete extra copies
of this application as needed to list the approved continuing education credits you h ave earned. Indicate
the certifying organization letter below in “ Group” *: (a) American Registry of Radiologic Technologists
(ARRT), (b) Medical Board of California, (c) Osteopathic Medical Board of California, (d) Podiatric
Medical Board of California, (e) California Board of Chiropractic Examiners, (f) Dental Board of California.
Course Title
Provider or Sponsor Provider Contact Information Date *Group Hours
Course Title
Prov
ider or S ponsor Provider Contact Information Date *Group Hours
Course Title
Provider
or
Spons
or Provider Contact Information Date
*Group Hours
Course
Title
Provider
or
Sponsor
Provider Contact Information Date
*Group Hours
REQUEST FOR CANCELLATION (optional)
Please note: If you request to cancel your certificate, you are not eligible for reinstatement and will need to reapply for
a new certificate.
I wish t o cancel one or more of my certificate categories. Please cancel the following certificate
categories:
I wish t o cancel ALL of my certificate(s). (Do not submit payment)
I certify that the information provided in this application for renewal is true and correct. I understand that the California
Department of Public Health may revoke certificates or permits that are procured by fraud, misrepresentation, or mistake, or 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.
Signature (Original Signature Required) Date
CDPH 8200 SRA III (Rev. 05/2020) Page 2 of 2
