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Board of Medical Imaging and Radiation Therapy

 

Employment Change in Address


 

State Mail is Not Forwarded


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RSA 328-J:16 Administrative Obligations of Licensees.

 

 

I. Licensees shall maintain their current business and home addresses on file with their governing boards. Any changes in address shall be provided to the office no later than 30 days from the date of the change.


II. Licensees shall notify their governing boards if licenses or other proof of licensure are lost or stolen.

 

General Information

 
 
1.   Last Name    (Type Answer) **Required
 
(100 character limit; 100 remaining.)
 
2.   First Name    (Type Answer) **Required
 
(100 character limit; 100 remaining.)
 
3.   Middle Initial    (Type Answer)
 
(100 character limit; 100 remaining.)
 
4.   License Number    (Type Answer) **Required
 
(100 character limit; 100 remaining.)
 
5.   Name of Employer    (Type Answer) **Required
 
(100 character limit; 100 remaining.)
 

Physical Address

This is the physical location of your place of Employment

 
 
6.   Address (Physical) **Required
 
Address Line 1:
Address Line 2:
City / State / Zip:

Mailing Address

This is the place where your Employer receives their mail

 
 
7.   Address (Mailing) **Required
 
Address Line 1:
Address Line 2:
City / State / Zip:

8.   Employers Phone Number (Example: 999-111-0000) **Required
  Ext:
 
9.   Employment E-Mail Address    (Select one) **Required
  Email   
I do not have a employment e-mail address   
 
10.   Anticipated start date    (Type Answer) **Required
 
(100 character limit; 100 remaining.)
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