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Get RADIOACTIVE MATERIAL REGISTRATION APPLICATION

5F Indianapolis, IN 46204 Type or clearly print all information. Complete all sections. Missing information may delay processing. Send the completed form to the address above. If you have any questions, call (317) 233-7147, Division of Medical Radiology Services or e-mail radiology isdh.in.gov . REGISTRATION NUMBER XN TYPE OF APPLICATION New Registration Two (2) Year Renewal Amendment REGISTRANT INFORMATION Name (Name of Company/Corporate) Telephone number ( ) Address Name of Radiatio.

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