"*" indicates required fields Step 1 of 5 20% Application for Registration of Designated Radiation Equipment In the province of Alberta, dental x-ray equipment and facilities as well as lasers, are governed by the Occupational Health and Safety Act. This Act specifies that owners of dental x-ray equipment and lasers must arrange the compliance verification/inspection and must ensure the final report is received by the Alberta Dental Association and College along with the completed registration application. Failure to comply with the Act and the Radiation Health and Safety Policy can result in additional fees and/or stop work orders associated with late registration or non-disclosed equipment. The Alberta Dental Association and College collects this information for the purposes of administration of the Radiation Health and Safety Program under the Alberta Radiation Protection Program. The information collected in this program will not be collected, used or disclosed for any other purpose except as otherwise permitted or required by law. We will retain this information indefinitely.’ Current Facility Name* Facility InformationType of Change*(Please Select One)No ChangeNew FacilityRelocationChange of NameFacility Opened* MM slash DD slash YYYY mm/dd/yyyyEffective Date* MM slash DD slash YYYY mm/dd/yyyyPrevious Facility Name (only Applies if Facility name is changed) Facility Contact Name* Dr.Manager Prefix First Last Email* Facility Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Facility Phone*Facility Fax Employer or Employer Designated Responsible DentistDo you wish to update the Employer or Employer Designated Responsible Dentist information?*NoYesIf not please continue to the next page.Employer Effective Date* MM slash DD slash YYYY mm/dd/yyyyEmployer Name* Employer Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email* Employer Phone*Employer FaxResponsible Dentist Information same as Employer above Information same as Employer above Employer Designated Responsible Dentist 1 Effective Date* MM slash DD slash YYYY mm/dd/yyyyEmployer Designated Responsible Dentist 1 Dr. Prefix First Last Employer Designated Responsible Dentist 1 Email* Employer Designated Responsible Dentist 2 Effective Date MM slash DD slash YYYY mm/dd/yyyyEmployer Designated Responsible Dentist 2 Dr. Prefix First Last Employer Designated Responsible Dentist 2 Email Equipment Information Complete this section of the form for each piece of equipment being registered; including Class 3b and Class 4 lasers.Do you wish to apply for registration or recertification of your radiation equipment?*NoYesIf not please continue to the next page.Name of Authorized Radiation Protection Inspection Agency that performed Compliance Inspection:* Date of Inspection* MM slash DD slash YYYY mm/dd/yyyyHow many Pieces of equipment are you applying for?12345678910If you are applying for more than 10 pieces of equipment please fill out the form again for the remaining pieces.#1 Employer or Employer Designated Responsible Dentist Name* Dr. Prefix First Last Equipment Status*(Please Select One)New5-Year RenewalRelocationReplacementEquipment Type*(Please Select One)IntraoralPanoramicPan / CephCephalometicTomographic (cone beam CT)Laser Class 3BLaser Class 4Location in Facility (Room Name)* Installation Date* MM slash DD slash YYYY mm/dd/yyyyManufacturer Name* Model Name* #2 Employer or Employer Designated Responsible Dentist Name* Dr. Prefix First Last Equipment Status*(Please Select One)New5-Year RenewalRelocationReplacementEquipment Type*(Please Select One)IntraoralPanoramicPan / CephCephalometicTomographic (cone beam CT)Laser Class 3BLaser Class 4Location in Facility (Room Name)* Installation Date* MM slash DD slash YYYY mm/dd/yyyyManufacturer Name* Model Name* #3 Employer or Employer Designated Responsible Dentist Name* Dr. Prefix First Last Equipment Status*(Please Select One)New5-Year RenewalRelocationReplacementEquipment Type*(Please Select One)IntraoralPanoramicPan / CephCephalometicTomographic (cone beam CT)Laser Class 3BLaser Class 4Location in Facility (Room Name)* Installation Date* MM slash DD slash YYYY mm/dd/yyyyManufacturer Name* Model Name* #4 Employer or Employer Designated Responsible Dentist* Dr. Prefix First Last Equipment Status*(Please Select One)New5-Year RenewalRelocationReplacementEquipment Type*(Please Select One)IntraoralPanoramicPan / CephCephalometicTomographic (cone beam CT)Laser Class 3BLaser Class 4Location in Facility (Room Name)* Installation Date* MM slash DD slash YYYY mm/dd/yyyyManufacturer Name* Model Name* #5 Employer or Employer Designated Responsible Dentist* Dr. Prefix First Last Equipment Status*(Please Select One)New5-Year RenewalRelocationReplacementEquipment Type*(Please Select One)IntraoralPanoramicPan / CephCephalometicTomographic (cone beam CT)Laser Class 3BLaser Class 4Location in Facility (Room Name)* Installation Date* MM slash DD slash YYYY mm/dd/yyyyManufacturer Name* Model Name* #6 Employer or Employer Designated Responsible Dentist* Dr. Prefix First Last Equipment Status*(Please Select One)New5-Year RenewalRelocationReplacementEquipment Type*(Please Select One)IntraoralPanoramicPan / CephCephalometicTomographic (cone beam CT)Laser Class 3BLaser Class 4Location in Facility (Room Name)* Installation Date* MM slash DD slash YYYY mm/dd/yyyyManufacturer Name* Model Name* #7 Employer or Employer Designated Responsible Dentist* Dr. Prefix First Last Equipment Status*(Please Select One)New5-Year RenewalRelocationReplacementEquipment Type*(Please Select One)IntraoralPanoramicPan / CephCephalometicTomographic (cone beam CT)Laser Class 3BLaser Class 4Location in Facility (Room Name)* Installation Date* MM slash DD slash YYYY mm/dd/yyyyManufacturer Name* Model Name* #8 Employer or Employer Designated Responsible Dentist* Dr. Prefix First Last Equipment Status*(Please Select One)New5-Year RenewalRelocationReplacementEquipment Type*(Please Select One)IntraoralPanoramicPan / CephCephalometicTomographic (cone beam CT)Laser Class 3BLaser Class 4Location in Facility (Room Name)* Installation Date* MM slash DD slash YYYY mm/dd/yyyyManufacturer Name* Model Name* #9 Employer or Employer Designated Responsible Dentist* Dr. Prefix First Last Equipment Status*(Please Select One)New5-Year RenewalRelocationReplacementEquipment Type*(Please Select One)IntraoralPanoramicPan / CephCephalometicTomographic (cone beam CT)Laser Class 3BLaser Class 4Location in Facility (Room Name)* Installation Date* MM slash DD slash YYYY mm/dd/yyyyManufacturer Name* Model Name* #10 Employer or Employer Designated Responsible Dentist* Dr. Prefix First Last Equipment Status*(Please Select One)New5-Year RenewalRelocationReplacementEquipment Type*(Please Select One)IntraoralPanoramicPan / CephCephalometicTomographic (cone beam CT)Laser Class 3BLaser Class 4Location in Facility (Room Name)* Installation Date* MM slash DD slash YYYY mm/dd/yyyyManufacturer Name* Model Name* This application has been verified and submitted by (must be Employer or Employer Designated Responsible Dentist of facility):Name* Dr. Prefix First Last Date Signed* MM slash DD slash YYYY Certification* I certify that the above information is complete and accurate.*The installation of the above equipment complies with all aspects of the Occupational Health and Safety Act and the Radiation Health and Safety Program. (The Employer or Employer Designated Responsible Dentist must certify). Δ