X-ray Service Provider Change of Information
This form can be submitted for all requests for changes of information for currently registered X-ray Service Providers.
For new registrations, please complete the
State of Idaho X-ray Service Provider
application.
Please provide this required information:
Please provide this required information:
Service Provider Registration Number:
Name of Company:
What information are you changing:
What information are you changing:
Company Name
Physical Address
Contact Person
Radiation Safety Officer
Telephone or Fax Number
E-mail Address
Mailing Address
Employees Working in Idaho
Company Information:
Company Information:
Company Name:
Physical Address:
Physical Address Line 2:
City, State, Zip Code:
Telephone:
Fax Number:
Contact Information:
Contact Information:
Contact Person:
Radiation Safety Officer
Email Address:
Mailing Address:
Mailing Address:
Attention:
Mailing Address:
Mailing Address Line 2:
Mailing City, State and Zip Code:
Please provide a list of all employees of this company working in Idaho:
Please provide a list of all employees of this company working in Idaho:
Submitted By (Full Name):
Title:
Phone number for questions regarding this form:
E-mail address for questions regarding this form:
Form Revised August 2017