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Office of Health Assurance and Licensing - RADON User Account Request
The below information is required to obtain secure access to RADMAT/RADON System. By submitting this request, you swear or affirm that you are authorized to perform business processes related to the ODH licensed professional below.
First Name:*
Last Name:*
Title:*
e-mail Address:*
Secondary Contact Name:

Reason for request (at least one reason is required):*





Technical Issue Description:*

License Information: (at least one selection required):*
(To enter multiple Radon Licenses separate them by comma ",". e.g. RT000,RT999,RT788)
    ODH License Number:  (e.g. RT000)
Or License Name/Entity: 
    ODH License Number:  (e.g. RS000)
Or Licensee Last Name: 
    ODH License Number:  (e.g. RC000)
Or License Name/Entity: 

I swear or affirm that the information provided herein, and any attachments hereto, have been prepared or carefully reviewed by me and constitute a truthful and correct disclosure of all information herein. I certify that the undersigned is the operator (if the operator is an individual), the president or other officer (if the operator is a corporation), a partner (if the operator is a partner), or an authorized agent of the operator.

ODH CONTACT INFORMATION
If you have a question regarding use of this form e-mail us at liccert@odh.ohio.gov.

    
* = Required field
Enhanced Information Dissemination Version 3.0
Software release on: 07/28/2016