BXC-001 (Revised 6/2022)
Page 1 of 2
New Jersey Department of Environmental Protection
Bureau of X-Ray Compliance
Radiation-Producing Machine Registration Application
Facility ID: ____________________ Registration Number: __________________
The Bureau issues the numbers for new facilities and all registrations.
New Facility Existing Facility-New Machine Temporary Registration (Start Date _______________)
Amended Registration Reason: We’ve Moved New Owner Machine Information (Section 6)
IMPORTANT: Both pages MUST BE COMPLETED when registering or modifying a machine registration.
Mail completed forms to BXC, PO Box 420, Mail Code 25-01, Trenton, New Jersey 08625-0420 or
Submit PDF forms to [email protected].gov
Phone: 609-984-5463 Fax: 609-984-5811 Website: www.xray.nj.gov
Registration information continued on page 2
1. FACILITY INFORMATION (Please print/type all information).
Facility Name_________________________________________________________________________
Facility Contact _______________________________________________________________________
Physical Address________________________________________________ Suite # ___________
City_____________________________ ST_____ Zip Code+4________+______ County__________
2. BILLING/MAILING ADDRESS (If different from item 1)
Mailing address____________________________________________ PO Box______ Suite #_________
City_____________________________ ST____ Zip Code+4_________+______ County______________
3. OWNER or RESPONSIBLE PARTY
Owner Name ________________________ ____ ___________________________ __________
First MI Last
Title (MD, DDS, DVM, etc)
Phone Number _______________________ EXT_________ Fax Number __________________________
Business E-mail__________________________________________________________________________
Discipline: Industrial Medical Dentist Chiropractor Podiatrist
Veterinarian Hospital School Government
4. MOBILE/MOTOR VEHICLE/TRAILER FACILITIES (only for equipment permanently mounted in vehicle)
Vehicle Information: Year_______ Make_____________________ Model________________________
State:_______ Plate #_______________ Vin #_______________________________________
Please enclose a copy of your vehicle registration.
5. REGULATORY REQUIREMENTS
1. The New Jersey Administrative Code (N.J.A.C.) 7:28-3.1(b) requires all owners of x-ray equipment to register
equipment within 30 days of acquisition.
2. Please see N.J.A.C. 7:28 et seq. for regulations regarding radiation safety surveys of the environs (www.xray.nj.gov);
Rules and Regulations
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BXC-001 (Revised 6/2022)
Page 2 of 2
New Jersey Department of Environmental Protection
Bureau of X-Ray Compliance
Radiation-Producing Machine Registration Application
Facility ID: ____________________ Registration Number: __________________
Mail completed forms to BXC, PO Box 420, Mail Code 25-01, Trenton, New Jersey 08625-0420 or
Submit PDF forms to [email protected].gov
Phone: 609-984-5463 Fax: 609-984-5811 Website: www.xray.nj.gov
All registration forms are two pages. Please complete both pages, sign and send to BXC.
6. MACHINE INFORMATION
Machine Category ____ ____ ____ Fee schedule location: http://www.state.nj.us/dep/rpp/reg/fees.htm
Date Acquired_____/ _____/ ________ Manufacturer _____________________________________
Model Name________________________ Generator Model No.* ________
_______________________
Generator Serial No.* _________________________ Tube Insert Serial No._________________________
Date Manufactured ________________ Location (Room ID) if applicable ________________________
Max kVp _________ Max mA____________ Max MeV_______ (therapy and industrial units only)
*Generator Model and Serial No. changes require a new registration form and radiation survey.
7. IMAGE RECEPTOR (Must check one)
DR - Digital Radiography CR/PSP- Computed Radiography/ Photo Stimulable Phosphor
Film – Automatic processing Film – Manual processing No film (Industrial x-ray units)
IMPORTANT Do NOT send check with registration application.
You will receive an invoice after the equipment has been registered.
8. SIGNATURE
_____________________________________________________ ____________________________________
Print Name (Owner or Responsible Party) Title
_________________________________________________ ____________________________________
Signature (Owner or Responsible Party) Date
For Bureau Use Only
Date Received _______________________ Date Returned________________________
