Form GEN-4 "Registration of Devices Possessed Under the General License Issued in Section C.4.2(B) of the Rules and Regulations for the Control of Radiation" - Rhode Island

What Is Form GEN-4?

This is a legal form that was released by the Rhode Island Department of Health - a government authority operating within Rhode Island. Check the official instructions before completing and submitting the form.

Form Details:

  • Released on September 1, 2007;
  • The latest edition provided by the Rhode Island Department of Health;
  • 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 Form GEN-4 by clicking the link below or browse more documents and templates provided by the Rhode Island Department of Health.

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Download Form GEN-4 "Registration of Devices Possessed Under the General License Issued in Section C.4.2(B) of the Rules and Regulations for the Control of Radiation" - Rhode Island

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Page 1 of
RHODE ISLAND RADIATION CONTROL AGENCY
REGISTRATION OF DEVICES POSSESSED UNDER THE
GENERAL LICENSE ISSUED IN SECTION C.4.2(b) OF THE
RULES AND REGULATIONS FOR THE CONTROL OF RADIATION
INSTRUCTIONS: Please review the attached instructions before completing this Registration form. Send the entire completed Registration to: RI
Department of Health, Radiation Control Agency, 3 Capitol Hill - Room 206, Providence, RI 02908-5097. You should keep a copy of your completed
Registration and attachments, as they will be incorporated into your General License by reference.
THIS SUBMISSION IS FOR (Check Appropriate Item)
NAME AND MAILING ADDRESS OF GENERAL LICENSEE:
1.
2.
( ) NEW REGISTRATION
[$320 Registration Fee Required]
( ) UPDATE TO REGISTRATION
( ) OTHER (Specify)
ACTUAL ADDRESS AT THE LOCATION OF USE (No P.O. Boxes, include Zip Code):
3.
NAME AND TITLE OF RESPONSIBLE INDIVIDUAL:
TELEPHONE NUMBER:
4.
NEW DEVICE(S) INFORMATION: Complete Agency Form GEN-4A
( ) Not Applicable
5.
DEVICE(S) NO LONGER POSSESSED BY GENERAL LICENSEE:
6.
Complete Agency Form GEN-4B
( ) Not Applicable
( ) No changes in General License information since last submission on:
7.
[Check if applicable for this Update. This item is not applicable for a New Registration]
CERTIFICATION (Must be completed):
8.
I hereby certify that:
All information contained in this registration is true and complete to the best of my knowledge and belief.
A.
A physical inventory of the devices subject to registration has been completed, and the device information on this form (and any
B.
continuation sheets, if applicable) has been checked against the device labeling.
I am aware of the requirements of the general license, provided in Section C.4.2(b) of the Rules and Regulations for the Control
C.
of Radiation.
(Signature of Responsible Individual listed in Item 4)
(Date)
FOR AGENCY USE ONLY
Correct fee submitted for New Registration: ( ) Yes No ( ) NA ( )
Information agrees with data provided to Agency by GL device manufacturer/distributor: ( ) Yes No ( ) NA ( )
Registration number assigned: GEN4-
FORM GEN-4 (September 2007)
Replaces Form GEN-4 (January 2005) Which Is Obsolete
Page 1 of
RHODE ISLAND RADIATION CONTROL AGENCY
REGISTRATION OF DEVICES POSSESSED UNDER THE
GENERAL LICENSE ISSUED IN SECTION C.4.2(b) OF THE
RULES AND REGULATIONS FOR THE CONTROL OF RADIATION
INSTRUCTIONS: Please review the attached instructions before completing this Registration form. Send the entire completed Registration to: RI
Department of Health, Radiation Control Agency, 3 Capitol Hill - Room 206, Providence, RI 02908-5097. You should keep a copy of your completed
Registration and attachments, as they will be incorporated into your General License by reference.
THIS SUBMISSION IS FOR (Check Appropriate Item)
NAME AND MAILING ADDRESS OF GENERAL LICENSEE:
1.
2.
( ) NEW REGISTRATION
[$320 Registration Fee Required]
( ) UPDATE TO REGISTRATION
( ) OTHER (Specify)
ACTUAL ADDRESS AT THE LOCATION OF USE (No P.O. Boxes, include Zip Code):
3.
NAME AND TITLE OF RESPONSIBLE INDIVIDUAL:
TELEPHONE NUMBER:
4.
NEW DEVICE(S) INFORMATION: Complete Agency Form GEN-4A
( ) Not Applicable
5.
DEVICE(S) NO LONGER POSSESSED BY GENERAL LICENSEE:
6.
Complete Agency Form GEN-4B
( ) Not Applicable
( ) No changes in General License information since last submission on:
7.
[Check if applicable for this Update. This item is not applicable for a New Registration]
CERTIFICATION (Must be completed):
8.
I hereby certify that:
All information contained in this registration is true and complete to the best of my knowledge and belief.
A.
A physical inventory of the devices subject to registration has been completed, and the device information on this form (and any
B.
continuation sheets, if applicable) has been checked against the device labeling.
I am aware of the requirements of the general license, provided in Section C.4.2(b) of the Rules and Regulations for the Control
C.
of Radiation.
(Signature of Responsible Individual listed in Item 4)
(Date)
FOR AGENCY USE ONLY
Correct fee submitted for New Registration: ( ) Yes No ( ) NA ( )
Information agrees with data provided to Agency by GL device manufacturer/distributor: ( ) Yes No ( ) NA ( )
Registration number assigned: GEN4-
FORM GEN-4 (September 2007)
Replaces Form GEN-4 (January 2005) Which Is Obsolete
Rhode Island Department of Health
3 Capitol Hill, Providence RI, 02908-5097
MANDATORY ADDENDUM TO LICENSE APPLICATION
Tax Payer Status Affidavit / Identity Verification
All persons applying or renewing any license, registration, permit or other
authority (herein after called “licensee”) to conduct a business or occupation in
the state of Rhode Island are required to file all applicable tax returns and pay all
taxes owed to the state prior to receiving a license as mandated by state law
(RIGL 5-76) except as noted below.
In order to verify that the state is not owed taxes, licensees are required to
provide their Social Security Number, or Federal Tax Identification Number (for
businesses) as appropriate. These numbers will be transmitted to the Division of
Taxation to verify tax status prior to the issuance of a license.
Licensee Declaration
I hereby declare, under penalty of perjury, that I have filed all required
state tax returns and have paid all taxes owed.
I have entered a written installment agreement to pay delinquent taxes
that is satisfactory to the Tax Administrator.
I am currently pursuing administrative review of taxes owed to the state.
I am in federal bankruptcy. (Case # ___________________________)
I am in state receivership. (Case # ___________________________)
I have been discharged from Bankruptcy.
(Case # ___________________________)
Type of Professional/Business License for which you are applying
___________________________
____________________________
Full Name (Please Print or Type)
Social Security Number (or FEIN for Business)
____________________________________
______________________________________
Signature
Phone Number (including area code if not 401)
___________________________________
____________________________________
Date
Name of Business (If Applicable)
This form must be completed, signed and attached to your license application for processing.
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