Affirmation For License To Operate An X-Ray Bureau Or Laboratory {C-100.2}

C-100.2 - AFFIRMATION FOR LICENSE TO OPERATE AN X-RAY BUREAU OR LABORATORY. This form is used in accordance with Workers' Compensation Law § 13-c. It collects information about the facility intending to operate an X-ray bureau or laboratory. The form includes details such as the facility's name, phone number, federal tax ID number, Department of Health registration number, the name of the facility director or supervising physician, the person in charge of radiation safety (Radiation Safety Officer), the date of the first day of operation, and the date of the last inspection if applicable. The individual completing the form affirms that the facility is registered with the Department of Health as an installation that ionizes radiation through the operation of radiation equipment and will comply with applicable rules and regulations. The affirmation is made under the penalties of perjury under the laws of New York. www.FormsWorkflow.com