DEQ Form 410-5-1 "Application for Industrial Radiography Examination" - Oklahoma

What Is DEQ Form 410-5-1?

This is a legal form that was released by the Oklahoma Department of Environmental Quality - a government authority operating within Oklahoma. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on April 1, 2018;
  • The latest edition provided by the Oklahoma Department of Environmental Quality;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of DEQ Form 410-5-1 by clicking the link below or browse more documents and templates provided by the Oklahoma Department of Environmental Quality.

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Download DEQ Form 410-5-1 "Application for Industrial Radiography Examination" - Oklahoma

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OKLAHOMA DEPARTMENT OF ENVIRONMENTAL QUALITY
DEQ Form 410-5-1
LAND PROTECTION DIVISION
(Rev. 04/18)
RADIATION MANAGEMENT SECTION
APPLICATION FOR INDUSTRIAL RADIOGRAPHY EXAMINATION
** PLEASE COMPLETE IN FULL AND TYPE OR PRINT LEGIBLY IN BLACK INK **
Submit the original form and fee ($149.32 for all exams) payable to the Oklahoma Department of Environmental Quality, to P.O. Box
2036, Oklahoma City, OK 73101. If you would like to pay by credit card, please call (405) 702-1130 (MC and Visa Only)
1. PRINT FULL NAME (Last, First, Middle):
2. SOCIAL SECURITY NUMBER:
3. RESIDENCE ADDRESS (Street, Apt. No., City, State, Zip Code):
4. EMAIL ADDRESS: (you will be notified via
email if you have been seated for your exam
date of choice)
5. RESIDENCE TELEPHONE NO:
6. DATE OF BIRTH:
7. MAIL RESULTS/I.D. CARD TO:
(MM/DD/YY)
(
)___________________
RESIDENCE
EMPLOYER
8. PRESENT EMPLOYER: (If Applicable)
Company Name:
Co. License No: ________________________
Mailing Address:
Co. Telephone No: (
) _________________________
City, State, Zip Code:
Co. Fax No: (
) _________________________
9. TYPE OF EXAMINATION: (Check One)
10. CATEGORY OF EXAMINATION: (Check One)
Initial
1- Radioactive Materials Only (RAM)
Re-Examination
3 - Both (RAM and X-Ray)
Renewal/Card No:________ Expires ________
Date
11. EXAMINATION DATE CHOICES: (you may not be seated for your first choice, please include a second choice)
1.___________________________________________
2. _____________________________________________
12. CERTIFICATION: I certify that the information contained herein is true and correct to the best of my knowledge.
_______________________________________
___________________________________________________________
DATE
SIGNATURE OF APPLICANT
FOR AGENCY USE ONLY
Documents
Examination Date ________________________________
On File:
* 410-5-2
*
410-5-3
(RAM)
Examination Code No. ____________________________
Citizenship Affidavit
410-5-3
(X-RAY)
Final Grade_____________________________________
Photo I.D. Card:
Identification No._________________________________
OK Driver's License
OK I.D. Card
Qualification Code________________________________
Expiration Date__________________________________
Other__________________________________________
Card No.__________________________________
Expiration Date__________________________________
Date I.D. Card Mailed_____________________________
Prior Approval from Agency after
Suspension or Revocation of I.D. Card
Date Results Mailed______________________________
_______________________________________________
AGENCY REPRESENTATIVE'S SIGNATURE
OKLAHOMA DEPARTMENT OF ENVIRONMENTAL QUALITY
DEQ Form 410-5-1
LAND PROTECTION DIVISION
(Rev. 04/18)
RADIATION MANAGEMENT SECTION
APPLICATION FOR INDUSTRIAL RADIOGRAPHY EXAMINATION
** PLEASE COMPLETE IN FULL AND TYPE OR PRINT LEGIBLY IN BLACK INK **
Submit the original form and fee ($149.32 for all exams) payable to the Oklahoma Department of Environmental Quality, to P.O. Box
2036, Oklahoma City, OK 73101. If you would like to pay by credit card, please call (405) 702-1130 (MC and Visa Only)
1. PRINT FULL NAME (Last, First, Middle):
2. SOCIAL SECURITY NUMBER:
3. RESIDENCE ADDRESS (Street, Apt. No., City, State, Zip Code):
4. EMAIL ADDRESS: (you will be notified via
email if you have been seated for your exam
date of choice)
5. RESIDENCE TELEPHONE NO:
6. DATE OF BIRTH:
7. MAIL RESULTS/I.D. CARD TO:
(MM/DD/YY)
(
)___________________
RESIDENCE
EMPLOYER
8. PRESENT EMPLOYER: (If Applicable)
Company Name:
Co. License No: ________________________
Mailing Address:
Co. Telephone No: (
) _________________________
City, State, Zip Code:
Co. Fax No: (
) _________________________
9. TYPE OF EXAMINATION: (Check One)
10. CATEGORY OF EXAMINATION: (Check One)
Initial
1- Radioactive Materials Only (RAM)
Re-Examination
3 - Both (RAM and X-Ray)
Renewal/Card No:________ Expires ________
Date
11. EXAMINATION DATE CHOICES: (you may not be seated for your first choice, please include a second choice)
1.___________________________________________
2. _____________________________________________
12. CERTIFICATION: I certify that the information contained herein is true and correct to the best of my knowledge.
_______________________________________
___________________________________________________________
DATE
SIGNATURE OF APPLICANT
FOR AGENCY USE ONLY
Documents
Examination Date ________________________________
On File:
* 410-5-2
*
410-5-3
(RAM)
Examination Code No. ____________________________
Citizenship Affidavit
410-5-3
(X-RAY)
Final Grade_____________________________________
Photo I.D. Card:
Identification No._________________________________
OK Driver's License
OK I.D. Card
Qualification Code________________________________
Expiration Date__________________________________
Other__________________________________________
Card No.__________________________________
Expiration Date__________________________________
Date I.D. Card Mailed_____________________________
Prior Approval from Agency after
Suspension or Revocation of I.D. Card
Date Results Mailed______________________________
_______________________________________________
AGENCY REPRESENTATIVE'S SIGNATURE