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Update Registration

Update Registration

1Update Registration Information
2Add Machines
3Remove Machines
4Update Machines
5Review
6Sign & Submit

Facility Information

Status Reason

Is this submission related to a violation issued by CDPH-RHB?

*

Is this submission related to a violation issued by CDPH-RHB? NoIs this submission related to a violation issued by CDPH-RHB? Yes

Type of Facility

Other

*

Is the facility a mammography provider?

*

Is the facility a mammography provider? NoIs the facility a mammography provider? Yes

Does your facility use X-ray machines with energies that exceed 500kVp?

*

Does your facility use X-ray machines with energies that exceed 500kVp? NoDoes your facility use X-ray machines with energies that exceed 500kVp? Yes

Facility Contact Information

This should be an individual that a CDPH-RHB representative may contact regarding any information provided on this form.

First Name

**

Last Name

**

Email Address

***

Phone

**

Registrant and Address Information

Please complete all data fields in the left column of the form which represents the information currently on file with CDPH-RHB.

Select the update checkbox if you need to provide updated registrant and/or address information to CDPH-RHB.

Update Info

Registrant Name

**

Updated Registrant Name

*

Doing Business As (DBA) Name

*

Updated DBA Name

*

Business Phone Number

*

Updated Business Phone Number

*

Registration Number (FAC)

*

Click if Registration Number (FAC) is Pending

Physical Address (cannot be P.O. Box)

Update Address

Street

**

Updated Street

*

Suite

*

Updated Suite

*

City

**

Updated City

*

State

Updated State

ZIP Code

**

Updated ZIP Code

*

Is mailing address the same as physical address?

Mailing Address

Mailing Street

*

Mailing City

*

State

ZIP Code

*

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