AUTHORIZATION TO USE X-RAY PRODUCING EQUIPMENT
AUTHORIZED USER
Name____________________________ Office_________________ Auth. # _____________
Dept_____________________________ Phone_________________ Date________________
EQUIPMENT
Type_________________________ Man. & Model #___________________________________
Serial # _______________________ kVp/mA _________________ Location ________________
USERS
____________________________
____________________________
____________________________
APPLICANT____________________________________ DATE _________________
DEPT HEAD____________________________________ DATE_________________
SAFETY OFFICE________________________________ DATE___________________