R-60 Radiation Machine Sales and Service Companies New and Renewal Registration form

This form is an application for registration as a Colorado Service Company for performing the following services: selling, leasing, transferring, lending, assembling, installing, maintaining, repairing, storing, trading out, disabling or disposing of radiation machines and related components.

The registration is for a one year period. Renewals must be received 30 days prior to the expiration date. Please refer to 6 CCR 1007-1 Colorado Rules and Regulations Pertaining to Radiation Control Part 2, 2.4.2 and Appendix 2H for additional information.

Application fee: $100.00

Service company information

Are you a new or renewing service company?

New service company.

Renewing service company.

Service company #

Service company's registration expiration date +

Company name

Company's street address

City

State

Zip code

Is the mailing address different than the street address?

Yes

No

Company's mailing address

Mailing city

Mailing address state

Mailing address zip

Contact first name

Contact last name

Contact email

Confirm email

Office phone

Mobile phone

Preferred contact method:

Email

Office phone

Mobile phone

Sales: Does your company only perform sales in Colorado but no service work such as maintenance?

Yes, we only perform sales without service work.

No, we perform both sales and service work.

Service categories requested: Check all that apply:

Healing Arts (excluding dental, mammography)

Dental

Mammography

Clinical Radiation Therapy

Analytical – Non Healing Arts (Includes package scanners, PMIs, cabinet analytical)

Industrial accelerator

Personnel dosimetry monitoring. Are all technicians performing service work in Colorado in possession of personnel dosimeters to monitor occupational dose limits as outlined in 6 CCR 1007-1, Part 4.6?

Yes

No

Personnel dosimetry supplier

Dosimetry supplier’s NVLAP lab code

Instrumentation calibration. Will the applicant perform all services with instruments in compliance with 6 CCR 1007-1, Part 2 that are sufficiently sensitive to determine compliance with these regulations, are maintained in good working order, and shall be calibrated at least every two (2) years, or in accordance with the manufacturer's recommendation, whichever is more frequent, or after any repair that could affect the calibration of the instrument?

Yes

No

Do you have service technicians that are renewing?

Yes

No

How many technicians are renewing their registration? You can choose as many as thirty (30). If you have more than thirty (30) technicians to add, you will need to fill out a second form.