Pacific Radiation Corporation, 2945 Stonehill Drive, Altadena, CA 91001 (626) 798-8100 www.pacificrad.com Application for NRRPT® Registration Maintenance Points Program Technologist Section Technologist Printed Name: _______________________________ Year Registered _________ Technologist Job Title: _________________________________________________________ Mailing Address: ______________________________________________________________ ___________________________________________________________________________ Daytime Telephone Number: _____________________________________________________ I hereby apply to Pacific Radiation Corporation for (circle one) 2 4 6 NRRPT® Registration Maintenance Points. I have arranged for my work supervisor named below to act as Proctor for my RM Points Examination. I understand that I will be allowed 45 minutes for each 35 questions and I agree to take the exam under closed book, closed notes conditions using only a non- programmable scientific calculator and that I will receive no outside assistance during the exam. Technologist Signature _________________________________ Date Signed ______________
Proctor Section Proctor Printed Name: __________________________________ Proctor Job Title: _____________________________________________________________ Mailing Address for Exam: ______________________________________________________ ___________________________________________________________________________ Daytime Telephone Number: _____________________________ I hereby certify that I am personally acquainted with the NRRPT® Technologist named above and that I supervise the work of this Technologist. I agree to act as Proctor for the NRRPT® RM Points Examination, that I will be physically present in the room with the examinee during the 45 to 90 minute exam and will do my best to assure that the examinee receives no outside assistance or uses any books or notes or other study aids during the exam except a non-programmable scientific calculator. I further agree to maintain strict confidentiality over the exam papers before, during and after the examination and agree to promptly return the completed exam to Pacific Radiation. Proctor Signature ________________________________________ Date Signed ____________ Payment Section Please complete this worksheet and then send payment in the form of a Money Order or personal or company check along with this Application. Choose one of the following number of RM points and then, in the next section, indicate which exam is being purchased to be mailed to your Proctor. Registration Maintenance Points ____ I am applying for 2 RM Points $50 ____ I am applying for 4 RM Points $100 ____ I am applying for 6 RM Points $150 Exam and Component Purchase ____ I am purchasing the complete Self Study Course. Please send my Proctor the Self Study Course final exam which I will take for 6 RM Points $700 ____ I am applying for 6 RM Points. Please send my Proctor the Exam for the complete Self Study Course $100 ____ I am applying for 2 RM Points. Please send my Proctor the Exam for the Unit circled here: THEORY INSTRUMENTATION OPERATIONS $50 ____ I am applying for 4 RM Points. Please send my Proctor the Exams for the two Units circled here: THEORY INSTRUMENTATION OPERATIONS $100 ____I also want to purchase the 4th edition text Basic Radiation Protection Technology in the format circled here: SOFTCOVER CD-ROM $95 ____ I also want to purchase the 4th edition Student Manual $260 ____ I also want to purchase the 4th edition Audio Tape Cassettes $120 ____ I also want to purchase the 4th edition Reference Package $260 Total for boxes checked above $ _______ Shipping/Handling from below $_______ GRAND TOTAL INCLUDED HERE $ _______
Complete Self Study Course, Ground UPS $20, 2nd day air $47. Examinations, US Mail $1. Softcover Textbook, Ground UPS $10, 2nd day air $17.40 CD-ROM Text, Ground UPS $5, 2nd day air $10. Student Manual, Ground UPS $10, 2nd day air $17.40 Audio Tape Cassettes, Ground UPS $10, 2nd day air $17.40 Reference Package, Ground UPS $10, 2nd day air $17.40 The acronym NRRPT® is a registered trademark of the National Registry of Radiation Protection Technologists |