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Please read these instructions completely before completing and mailing the application. Any
missing documents will delay the processing of your application. Any reference to
“licensure” in the application also means “certification” and “registration.”
DH 1005, 10/15 (replaces all previous versions), Rule 64E-3.003, F.A.C. APPLICATION FEES ARE NOT REFUNDABLE
GENERAL INFORMATION AND INSTRUCTIONS FOR
APPLICATION FOR RADIOLOGIC TECHNOLOGY CERTIFICATION
General Radiographer
Nuclear Medicine Technologist
Radiation Therapy Technologist
Computed Tomography
Positron Emission Tomography
Mammography
Radiologist Assistant
1) REQUIREMENTS FOR APPLICATION:
To be eligible for certification, you must have successfully completed an approved educational/training program in
the same area of radiologic technology for which you are applying for certification. Such programs must be
recognized and accepted by the American Registry of Radiologic Technologists (ARRT) or the Nuclear Medicine
Technology Certification Board (NMTCB) – (contact information for all approved programs, including the accredited
school/college name, address and program director’s name, is found on the registry websites at http://www.arrt.org
and http://www.nmtcb.org).
If you are currently licensed as a radiographer, nuclear medicine technologist, radiation therapy technologist or
radiologist assistant by a national organization (the ARRT or NMTCB), or a state who uses the ARRT examinations,
and you are applying for the same license type, then you may check “by-endorsement” on the application form,
pay the certification by endorsement fee, and include a current copy of your license (or wallet card) which shows
your expiration date, name, and type of licensure. You may also apply by endorsement for a specialty license type
if you currently have the same license from one of the approved organizations and types listed in Florida
Administrative Code (F.A.C.) Rule 64E-3.0034.
If you are not currently licensed, then you need to check “by-examination” and pay the certification by examination
fee (however, as noted in section 4 of the application, not all license types are available for licensure by
examination under state law). This application type should also be used for those graduates of an approved
program who are currently scheduled for a national examination.
Regardless of whether you apply by exam or by endorsement, we cannot grant certification until you have passed
the State of Florida examination, or one of the national registry exams as noted above, with a scaled score of 75.
2) ALL APPLICANTS MUST SUBMIT:
a. Proof of education. Submit proof of completion of the highest level of training in this field you have
completed (college, university, hospital-based program, etc.).
b. Verification of licensure from each state or organization where you have been disciplined or denied
licensure. It is your responsibility to send the License Verification Form, DH 4128, to each state or
organization.
c. Proof of age. Submit a copy of your valid Driver’s License or other government-issued ID showing date of
birth. You must be at least 18 to be certified.
3) ALL FORMS ARE AVAILABLE FOR DOWNLOAD AT:
http://www.floridahealth.gov/licensing-and-regulation/radiologic-technology/applications-forms/.
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4) HIV/AIDS AFFIDAVIT:
Florida law requires all applicants to complete an approved 4-hour HIV/AIDS education course that contains
instruction on Florida’s HIV/AIDS laws. You must submit proof of completion in accordance with s. 381.0034,
Florida Statutes. Courses can be located at: http://srdappsdoh.doh.state.fl.us/RadTech/CeProviders.aspx
.
5) APPLICANTS WHO WERE EDUCATED OUTSIDE OF THE UNITED STATES:
If an applicant cannot meet the requirements for graduation from an approved educational or training program
solely because their radiologic technology education was received in a country other than the United States (U.S.),
beyond the reach of U.S. accreditation mechanisms, the applicant may instead submit evidence that the radiologic
technology education they received in the other country was substantially equivalent to the approved educational or
training program required by the department. The department will determine, based on this evidence, whether the
applicant’s education is substantially equivalent. All documents not in English must be accompanied by a certified
translation in English. Such evidence must include:
a. A license or registration in the applicant’s name to practice radiologic technology in the other country;
b. An official transcript of the applicant’s radiologic technology education in the other country, showing all
courses successfully completed, the grade received, the applicant’s full name, the graduation date, and the
degree awarded; and
c. A comprehensive, course-by-course evaluation of the U.S. equivalency of the applicant’s radiologic
technology education by an international credential evaluation service which is a member of the National
Association of Credentials Evaluations Services, at: http://www.naces.org
.
6) DISCIPLINE OR DENIAL OF ANY HEALTH CARE LICENSE/CERTIFICATE OR BY ANY ORGANIZATION:
Disciplinary action includes revocation, suspension, probation, reprimand, or being otherwise acted against,
including being denied certification or resigning from or non-renewal of membership taken in lieu of or in settlement
of a pending disciplinary denied certification or resigning from or non-renewal of membership taken in lieu of or in
settlement of a pending disciplinary case.
7) CRIMINAL BACKGROUND:
If you answer YES to the criminal history question (#7), you must submit the listed documentation and
Background History Report Form, DH 4127, for EACH incident.
Law enforcement background check from each state where a misdemeanor or felony occurred. For offenses
committed in Florida, contact the Florida Department of Law Enforcement at: http://www.fdle.state.fl.us.
Letter of eligibility from the ARRT (if you applied for certification with the ARRT).
Copies of arrest report(s), court documents showing sentence, proof of completing all terms of sentence,
including rehabilitation/treatment programs, proof of restoration of civil rights, if such rights were removed due to
felony conviction.
Reference letters and any other information/documents you would like taken into consideration.
8) Certificates expire the last day of your birth month, every other year. Initial certificates will be issued for no less
than 12 or no more than 24 months, s. 468.307(1), Florida Statutes.
9) ADA REQUESTS: Please contact the ARRT at 651-687-0048, ext. 3155.
10) EXAMINATION FEES are payable directly to the ARRT at: https://www.staterhc.org/state/fl/login.aspx. You will not
be eligible to pay for your exam until you are approved by the Florida Certification Office and have received an
eligibility letter with payment instructions.
11) EXAMINATION SCORES will not be mailed to you. They will be available approximately 14 days after you sit for
the exam at: https://appsmqa.doh.state.fl.us/onlinetestnet/default.aspx.
12) An incomplete application expires six (6) months after initial filing with the department, s. 468.304(2), Florida
Statutes.
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BEFORE YOU MAIL YOUR APPLICATION:
Have all questions on the application been answered or marked N/A?
Is your application typed or filled out in ink, signed and dated?
Have you enclosed all requested educational and licensure documents?
Have you enclosed your 4-hour HIV/AIDS course documents?
Have you enclosed a money order or cashier’s check for the application fee?
If you answered YES to the criminal history or discipline questions, have you enclosed the required
documents?
CONTACT INFORMATION:
MQA Call Center - General Information: 850-488-0595
EMT/Paramedic/Radiologic Technology Certification Office:
Website: http://www.floridahealth.gov/licensing-and-regulation/radiologic-technology/
E-mail: mqa.rad-[email protected]
Forms: http://www.floridahealth.gov/licensing-and-regulation/radiologic-technology/applications-forms/
Address Change/ Update Profile:
https://appsmqa.doh.state.fl.us/mqaservices/login.asp?mult=&pass=Y&voprof=7601
Exam Results: https://appsmqa.doh.state.fl.us/onlinetestnet/default.aspx
License Verification: https://appsmqa.doh.state.fl.us/IRM00PRAES/PRASLIST.ASP
Mailing Address for the Application Fees: Florida Department of Health
EMT/PMD/Rad Tech Certification Office
P.O. Box 6330
Tallahassee, Florida 32314-6330
Mailing Address for Any Correspondence
Containing No Fees: Florida Department of Health
EMT/PMD/Rad Tech Certification Office
4052 Bald Cypress Way, Bin C-85
Tallahassee, Florida 32399-3285
The practice and disciplinary guidelines of each profession listed on this application is regulated under
Chapter 468, Part IV, Florida Statutes, and F.A.C. Chapter 64E-3. Both documents are available at:
http://www.floridahealth.gov/licensing-and-regulation/radiologic-technology/resources
.
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Please TYPE or PRINT in ink in CAPITAL LETTERS. Read instructions carefully before completing. All sections of this
application are required to be completed unless otherwise noted. Omissions will delay processing.
Pursuant to Chapter 468, Part IV, Florida Statutes, no person shall use radiation on a human being or otherwise practice radiologic
technology unless he or she is certified or licensed by the State of Florida as a radiologic technologist, radiologist assistant, basic
x-ray machine operator, physician, podiatrist, chiropractor, or naturopath.
DH 1005, 10/15 (replaces all previous versions), Florida Administrative Code, Rule 64E-3.003 APPLICATION FEES ARE NOT REFUNDABLE
APPLICATION FOR RADIOLOGIC TECHNOLOGY CERTIFICATION:
General Radiographer
Nuclear Medicine Technologist
Radiation Therapy Technologist
Computed Tomography
Positron Emission Tomography
Mammography
Radiologist Assistant
1. APPLICANT INFORMATION:
____________________________________________________________________________________________ _______/_______/___________
Last Name First Name Middle Initial Date of Birth
________________________________________________________________________________________________________________________
Mailing Address for Correspondence City State Zip Code
If your mailing address is a P.O. Box, provide your street address as well.
Daytime phone # (_______)_________________ Home phone # (_______)___________________ Email __________________________________
2. PERSONAL INFORMATION: This section is optional.
Gender: Male Female
Ethnicity:
White Native American Asian/Pacific Islander Black Hispanic Other_______________
3. Would you be available to provide health care services in special needs shelters or to help staff disaster medical
assistance teams during times of emergency or major disaster if your employer releases you to do so?
Yes No
4. APPLICATION TYPE: Indicate below the type of certificate you seek and the method you wish to use to qualify for
certification in Florida. Limit one method per application. Please note as indicated below some certificates are available by
endorsement method only.
TYPE OF CERTIFICATE
METHOD OF QUALIFICATION
General Radiographer
(GR) (7601)
Exam $50.00
(1043)
Re-exam $35.00
(1051)
Endorsement $45.00
(1031)
Nuclear Medicine
Technologist (NMT) (7601)
Exam $50.00
(1042)
Re-exam $35.00
(1052)
Endorsement $45.00
(1031)
Radiation Therapy
Technologist (RTT) (7601)
Exam $50.00
(1041)
Re-exam $35.00
(1053)
Endorsement $45.00
(1031)
Computed Tomography
(CT) (7601)
N/A N/A
Endorsement $45.00
(1031)
Positron Emission Tomography
(PET) (7601)
N/A N/A
Endorsement $45.00
(1031)
Mammography
(M) (7601)
N/A N/A
Endorsement $45.00
(1031)
Radiologist Assistant
(RA) (7602)
N/A N/A
Endorsement $45.00
(1031)
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5. PROFESSIONAL EDUCATION: Submit a copy of your graduation certificate/diploma.
Indicate the type of program you completed:
General Radiographer Positron Emission Tomography
Nuclear Medicine Technologist Mammography
Radiation Therapy Technologist Radiologist Assistant
Computed Tomography
Other ______________________________________________________
Name, City and State of Program:_________________________________________________________________________
_____________________________________________________________________________________________________
Type of Diploma: Degree Certificate Graduation Date: ___________________
Type of Teaching Facility: College/University Junior/Community College Hospital
Military On-the-Job Training Other _____________________
6. LICENSURE/CERTIFICATION/REGISTRATION: (The term “licensure” as used here also means “certification” and
“registration.”)
a. Have you ever been licensed by any state or national organization (registry) in Radiologic Technology or in any
other health care field?
Yes No.
If YES, complete the table below for all such licenses and attach a copy of your current license or wallet card which shows
your expiration date.
Type of License License Number
Expiration
Date
Disciplinary
Action*
State
or
Organization
Radiographer
Nuclear Medicine
Technologist
Radiation Therapy
Technologist
Computed Tomography
Positron Emission
Mammography
Radiologist Assistant
Other (Specify)
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
b. Have you ever been denied licensure or had disciplinary action* taken against you or your health care license?
Yes No. (*Disciplinary action includes revocation, suspension, probation, reprimand, or being other wise acted
against, including being denied certification or resigning from or non-renewal of membership taken in lieu of or in
settlement of a pending disciplinary case.)
If YES, attach a written explanation for each action and have each state or organization which denied you or took action
against you fill out a License Verification Form (DH 4128) and send directly to our office.
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CRIMINAL BACKGROUND:
7. Have you ever been convicted of, pled nolo contendere (no contest) to, or had adjudication of guilt withheld for any
violation of any state or federal law in any jurisdiction?
Yes No.
If YES, please complete a Background History Form (DH 4127) for each offense and follow the instructions for submitting
complete information about your criminal background, including a law enforcement background check.
8. HIV/AIDS COURSE:
Have you completed the Florida-approved 4-hour HIV/AIDS course required under, s. 381.0034, Florida Statutes?
Yes No.
If YES, please enclose a copy of the course certificate. If NO, please see instructions for information on where to obtain this
course.
9. STATEMENT OF APPLICANT:
I, the undersigned:
Understand that furnishing false information in this application shall constitute cause for denial, suspension or revocation of
any certificate issued to me pursuant to this application.
Understand that the practice of my profession is governed by Chapter 468, Part IV, Florida Statutes, and Florida
Administrative Code, Chapter 64E-3, both of which are available at:
http://www.floridahealth.gov/licensing-and-regulation/radiologic-technology/resources
.
Agree to abide by all the rules and regulations of the State of Florida and to permit the State or its duly authorized
representative, at all reasonable times, opportunity to inspect my certificate.
Understand that Florida law requires me to immediately inform the Certification Office of any material change in any
circumstances or condition stated in the application which takes place between the initial filing and the final granting or denial
of the certificate and to supplement the information as needed.
OATH OR AFFIRMATION (Must Be Completed):
I, the undersigned, do swear or affirm that I am the person referred to in this application for certification in the State of Florida,
that I am at least 18 years of age, I am of good moral character and that I have carefully read the questions in the foregoing
application and have answered them completely, without reservations of any kind, and declare under penalty of perjury that
the answers and all statements made by me herein and attached are true and correct.
STATE OF ________________________
COUNTY OF ______________________
Sworn to (or affirmed) and subscribed before me this _______ day of __________________, 20______, by
________________________________________ who is________ personally known OR ________ produced identification.
Type of identification presented: ___________________________________________
___________________________________________
Signature of Notary Public
___________________________________________
Print, Type or Stamp Commissioned Name of Notary
[PURSUANT TO § 117.021, FLORIDA STATUTES, OATHS/AFFIRMATIONS CAN BE MADE ELECTRONICALLY.]
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CONFIDENTIAL AND EXEMPT FROM PUBLIC RECORDS DISCLOSURE*
General Radiographer
Nuclear Medicine Technologist
Radiation Therapy Technologist
Computed Tomography
Positron Emission Tomography
Mammography
Radiologist Assistant
Name:_______________________________________________________________________________________________
Last First Middle
Social Security Number: ______________________________________________________________________________
Applicant’s Signature: ____________________________________________ Date: __________________________
*This page is exempt from public records disclosure. The Department of Health is required and
authorized to collect Social Security Numbers relating to applications for professional licensure
pursuant to Title 42 USCA s. 666(a)(13). For all professions regulated under Chapter 468, Part IV,
Florida Statutes, the collection of Social Security Numbers is required by s. 468.304(2), Florida
Statutes.