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Board of Medical Imaging and Radiation Therapy

 

Home 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.)
 

Physical Address

This is the physical location of your house

 
 
4.   Physical Address **Required
 
Address Line 1:
Address Line 2:
City / State / Zip:

Mailing Address

This is the place where you receive your mail

 
 
5.   Mailing Address **Required
 
Address Line 1:
Address Line 2:
City / State / Zip:

6.   Phone Number    (Check all that apply) **Required
  Home Phone Number   
Cell Phone   
 
7.   Home E-Mail Address    (Select one) **Required
  Email   
I do not have a home e-mail address   
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