I certify by my signature below, under penalty of law, this application is prepared in conformity with the Colorado Department of Public Health and Environment’s 6CCR 1007-1 Rules and Regulations pertaining to Radiation Control and that all information contained herein, including any attachments is true, accurate and complete to the best of my knowledge and belief. I understand I must be approved as a provisional mammographer before performing mammography procedures in the State of Colorado.
For the purposes of this form, the Colorado Department of Public Health and Environment accepts your typed name and date as an electronic signature equivalent to your valid signature on a paper copy of the form. As such, this electronically completed form subjects the signatory to the same responsibilities as a hand-signed form. Per Section 18-8-306, C.R.S., it is a felony to submit false information to a state official.