Certificate Application

DUPLICATE CERTIFICATE AUTHORIZATION

THE AMERICAN REGISTRY OF RADIOLOGIC TECHNOLOGISTS® Duplicate Certificate Authorization Page 1 of 2 FORM DEC 2016

INSTRUCTIONS

(1) Print legibly and complete the form. Illegible of incomplete forms will be returned.

(2) You must be currently certified and registered to request a duplicate certificate.

(3) Each certificate reflects one discipline credential.

(4) Complete the application for one or more certificates on the reverse side.

(5) The certificate will bear your legal name as currently on record, along with your original certificate date and number.

(6) If your name has changed, you must include documentary evidence of your name change (copy of marriage certificate, etc.) and a Name Change Form downloadable from your ARRT online account’s “Settings” page. The new name to be printed on the duplicate certificate should be printed legibly.

(7) Have your signature notarized.

(8) Enclose the certificate fee of $10 for each certificate ordered.

(9) Mail the original application (photocopies not accepted) to ARRT, Initial Certification Department, 1255 Northland Drive, St Paul, MN 55120-1155

(10) Contact the Initial Certification Department with questions: 651-***-****, ext. 8560.

(11) Allow three to four weeks for delivery.

DUPLICATE CERTIFICATE AUTHORIZATION

THE AMERICAN REGISTRY OF RADIOLOGIC TECHNOLOGISTS® Duplicate Certificate Authorization Page 2 of 2 FORM DEC 2016

Read instructions on the reverse side before completing this application. CERTIFICATE CATEGORY

Select ALL desired categories.

R N T S MR CV M CT QM BD VS CI VI BS RRA

ARRT ID Number U.S. Social Security Number – – Birthdate MO DA YR

Last Name

First Name Middle Initial

Street Address 1

Street Address 2

City State Zip

If your name has changed, please provide name as originally certified. (For ARRT verification) Last Name

First Name Middle Initial

NOTARY

Before me personally appeared to me known to be the person described in the above application, who signed the foregoing instrument in my presence, and made oath before me to the accuracy of the statements set forth herein,

on the day of, 20 .

(Notary Public Signature)

NOTE: The declaration below must be signed in the presence of a Notary Public. I DECLARE THAT ALL THE DATA APPEARING ON THIS APPLICATION ARE ACCURATE AND TRUE TO THE BEST OF MY KNOWLEDGE.

(Applicant Signature) MO DA YR

NOTARY

STAMP/SEAL

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