ENVIRONMENT DEPARTMENT
Radiation Control Bureau
P.O. Box 26110Santa Fe, New Mexico 87502-6110
Telephone (505) 476-3236
Fax (505) 476-3232
Bureau Website
www.nmenv.state.nm.us/nmrcb/home.html /APPLICATION FOR REGISTRATION TO PROVIDE RADIOLOGICAL SERVICES
______
Name (of person and/or organization to be registered)
______
Address (street or box number)
______
City State/Province Zip/Postal Code
______
Telephone Number Fax Number
Does the applicant possess licensable quantities of radioactive materials? ____Yes ____No
If so, under which license number(s) and issuing agency(s) would you be performing services pursuant to your registration?
______
License Number Issuing Agency
______
License Number Issuing Agency
Specify the services for which certification/registration is desired (see list of categories):
______
______
______
______
Applicant Name (print) Signature Date Title
ALONG WITH THIS APPLICATION:
· Attach a thorough description of the scope of activities.
· For all personnel performing said service(s), submit documentation demonstrating training, experience, and qualifications appropriate to safely discharge the service(s) in accordance with the New Mexico Radiation Protection Regulations (20.3 NMAC).
· Attach all necessary biographical information.
/ State of New MexicoENVIRONMENT DEPARTMENT
Radiation Control Bureau
P.O. Box 26110Santa Fe, New Mexico 87502-6110
Telephone (505) 476-3236
Fax (505) 476-3232
Bureau Website
www.nmenv.state.nm.us/nmrcb/home.html /REGISTERING TO PROVIDE RADIOLOGICAL SERVICES
In accordance with Part 2, Section 204, of the New Mexico Radiation Protection Regulations governing application for Registration of Servicing and Services, please complete the attached form for registration and attach all pertinent documents. No fee is charged for registration. The Radiation Protection Program issues certificates of registration for the categories listed below:
Categories Requiring Registration
Calibration of Radiation Measurement Instruments
Calibration of Radiation Emitting Devices
Health Physics Consulting and Services
Installing, Servicing, or Providing Radiation Emitting Devices
Leak Testing of Radioactive Sources
Personnel Dosimetry Services
Radiation Safety Training
Indoor Radon Services
Persons and organizations registered with this State are required to possess adequate credentials for their particular disciplines. Along with your completed application, submit for consideration any information that proves qualification to perform the services requested. This includes résumés of the persons providing the services, a corporate résumé or overview, certifications, and letters of recommendation. For the discipline, also include copies of procedures for calibrating radiation measuring instruments, and outlines for training.
INSTRUCTIONS FOR SUBMITTING THE APPLICATION:
· Prior to submitting the application, the applicant, and all pertinent personnel employed by the applicant, are required to read and understand the requirements of the applicable sections of the New Mexico Radiation Protection Regulations (20.3 NMAC). The regulations are available on-line at:
http://www.nmenv.state.nm.us/nmrcb/regs.html
· Complete the form “Application for Registration to Provide Radiological Services”.
· Develop a description of the intended scope of activities.
· Develop a radiation protection program and operational procedures in accordance with the requirements of Part 4 and other applicable parts of the New Mexico Radiation Protection Regulations. A Radiation Safety Officer (RSO) must be appointed to manage the radiation protection program.
· Develop documentation demonstrating that the RSO(s) and all personnel working under the registration will possess adequate training, experience, and qualifications necessary to safely and adequately accomplish their duties.
· The application must be made by a person applying for individual registration, or an authorized principal in your business or organization.
· Send the documentation required herein to the Radiation Control Bureau at the address listed on this letterhead.
SPECIALTIES IDENTIFIED FOR EACH REGISTRATION CATEGORY
Below is a list of specialties identified by registration category. Specialties are not limited to those identified below.
Calibration of Radiation Measurement Instruments
N/A
Calibration of Radiation Emitting Devices
diagnostic or therapeutic in the healing arts
veterinary diagnostic or therapeutic
medical irradiators
industrial radiography, irradiators, diagnostic X-rays
Health Physics Consulting and Services
nuclear medicine
qualified expert in medical physics or health physics
radiation safety in the healing arts
veterinary
radiological control technology
density moisture gauges
industrial radiography, irradiators, diagnostic X-rays, stationary gauges
oil & gas NORM
radioanalytical laboratory
academic and/or research and development facilities
decontamination and decommissioning
Installing, Servicing, or Providing Radiation Emitting Devices
diagnostic or therapeutic in the healing arts
veterinary diagnostic or therapeutic
medical irradiators
industrial radiography, irradiators, diagnostic X-rays
Leak Testing of Radioactive Sources
N/A
Personnel Dosimetry Services
external dosimetry (requires current NVLAP certification)
internal dosimetry
bioassays
Radiation Safety Training
healing arts (medical or dental)
veterinary medicine
ancillary personnel
radiation safety officer (RSO)
radiological control technologist
radiological facility worker (radiation and contamination worker)
density moisture gauges
oil & gas NORM
industrial radiography, irradiators, diagnostic X-rays, stationary gauges
radioanalytical laboratory
decontamination and decommissioning
Indoor Radon Services
Consulting and/or Training
Measurement
Mitigation
Laboratory and/or Analytical Services