Annual Compliance Reporting Form Page 4
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4940E
PROTECTED WHEN COMPLETED
11.
Declaration by Radiation Safety Officer/Licence Contact Person
I, ________________________________________ (print name), having the authority to act for the
licensee pursuant to section 15 of the General Nuclear Safety and Control Regulations, certify that all
statements and representations made in this Annual Compliance Report and any supplementary pages
appended to this report are true and correct to the best of my knowledge.
Title: _______________________________
Date: ____________________________
It is an offence under the Nuclear Safety and Control Act to knowingly make a false report.
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