ARRA-PHYS https://arra.az.gov Phone (602) 255-4845
October 2016 4814 S. 40
th
St. Phoenix, AZ. 85040. xraywebform@azrra.gov
PHYSICS SUPPORT PERSONNEL
APPLICATION and/or RENEWAL
Please complete this application electronically. Save the completed form to your pc for your records, print, sign
application, and scan along with all requested supporting documentation. If possible, please combine application and
all supporting documentation into a single pdf and submit as an email attachment to xraywebform@azrra.gov
.
Submissions also accepted by fax and mail.
APPLICANT INFORMATION
Last Name First Name MI
Business Name
Mailing Address
Street No. or POB Suite City State Zip
Daytime Phone Fax Email
This application is for a (check one): New Applicant Renewal Applicant
ARS § 41-1080 requires NEW 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
.
SECTION A: MODALITY OF SUPPORT
Applicant is requesting approval to provide physics support for:
Diagnostic X-Ray (R12-1-102) X-ray Therapy(R12-1-611.01.M) Mammography (R12-1-615)
Other__________________________________________________________________________________
Applicant m
ust provide documentation that the training requirements in the corresponding state code
listed above have been met.
SECTION B: CERTIFICATION and EDUCATION
Professional Certification: Board Certified Board Eligible
Certifying Board: Specialty:
Please submit a copy of your board certification with this application.
Education: Highest Degree Acquired: Area of Study:
Please submit a copy of diploma with this application.
SECTION C: EXPERIENCE
Indicate the number of years you have provided physics support in each of the categories checked in section A.
Indicate the number of years experience under the supervision of an experienced physicist in the same categories.
SECTION D: MAMMOGRAPHY
1) Attach documentation of initial training. (if new applicant)
2) Indicate number of credit hours received within past 3 Years and attach documentation.
3) Indicate number of facilities surveyed in the last 2 years and attach a list.
4) Indicate number of units surveyed in the last 2 years.
SIGNATURE
The applicant executing this application certifies that this application has been prepared in accordance with Arizona Administrative
Code, Title 12, Chapter 1, and all information contained herein, including any supplements and attachments hereto, is true and correct
to the best of their knowledge and belief.
Signature of Applicant Date
X-ray:\forms\currentforms\physicistapp Oct 2016
click to sign
signature
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