Nrc Form 313 - Application For Materials License

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APPROVED BY OMB: NO. 3150-0120

EXPIRES: 10/31/2008

NRC FORM 313

U.S. NUCLEAR REGULATORY COMMISSION

Estimated burden per response to comply with this mandatory collection request: 4.4

(4-2008)

hours. Submittal of the application is necessary to determine that the applicant is

10 CFR 30, 32, 33,

qualified and that adequate procedures exist to protect the public health and safety.

34, 35, 36, 39, and 40

Send comments regarding burden estimate to the Records and FOIA/Privacy Services

Branch (T-5 F53), U.S. Nuclear Regulatory Commission, Washington, DC

20555-0001, or by internet e-mail to infocollects@nrc.gov, and to the Desk Officer,

Office of Information and Regulatory Affairs, NEOB-10202, (3150-0120), Office of

APPLICATION FOR MATERIALS LICENSE

Management and Budget, Washington, DC 20503. If a means used to impose an

information collection does not display a currently valid OMB control number, the NRC

may not conduct or sponsor, and a person is not required to respond to, the

information collection.

INSTRUCTIONS: SEE THE APPROPRIATE LICENSE APPLICATION GUIDE FOR DETAILED INSTRUCTIONS FOR COMPLETING APPLICATION.

SEND TWO COPIES OF THE ENTIRE COMPLETED APPLICATION TO THE NRC OFFICE SPECIFIED BELOW.

APPLICATION FOR DISTRIBUTION OF EXEMPT PRODUCTS FILE APPLICATIONS WITH:

IF YOU ARE LOCATED IN:

DIVISION OF INDUSTRIAL AND MEDICAL NUCLEAR SAFETY

ILLINOIS, INDIANA, IOWA, MICHIGAN, MINNESOTA, MISSOURI, OHIO, OR WISCONSIN, SEND

OFFICE OF NUCLEAR MATERIALS SAFETY AND SAFEGUARDS

APPLICATIONS TO:

U.S. NUCLEAR REGULATORY COMMISSION

WASHINGTON, DC 20555-0001

MATERIALS LICENSING BRANCH

U.S. NUCLEAR REGULATORY COMMISSION, REGION III

2443 WARRENVILLE ROAD, SUITE 210

ALL OTHER PERSONS FILE APPLICATIONS AS FOLLOWS:

LISLE, IL 60532-4352

IF YOU ARE LOCATED IN:

ALABAMA, CONNECTICUT, DELAWARE, DISTRICT OF COLUMBIA, FLORIDA, GEORGIA,

ALASKA, ARIZONA, ARKANSAS, CALIFORNIA, COLORADO, HAWAII, IDAHO, KANSAS,

KENTUCKY, MAINE, MARYLAND, MASSACHUSETTS, NEW HAMPSHIRE, NEW JERSEY,

LOUISIANA, MISSISSIPPI, MONTANA, NEBRASKA, NEVADA, NEW MEXICO, NORTH

NEW YORK, NORTH CAROLINA, PENNSYLVANIA, PUERTO RICO, RHODE ISLAND, SOUTH

DAKOTA, OKLAHOMA, OREGON, PACIFIC TRUST TERRITORIES, SOUTH DAKOTA, TEXAS,

UTAH, WASHINGTON, OR WYOMING, SEND APPLICATIONS TO:

CAROLINA, TENNESSEE, VERMONT, VIRGINIA, VIRGIN ISLANDS, OR WEST VIRGINIA,

SEND APPLICATIONS TO:

LICENSING ASSISTANCE TEAM

NUCLEAR MATERIALS LICENSING BRANCH

DIVISION OF NUCLEAR MATERIALS SAFETY

U.S. NUCLEAR REGULATORY COMMISSION, REGION IV

U.S. NUCLEAR REGULATORY COMMISSION, REGION I

612 E. LAMAR BOULEVARD, SUITE 400

475 ALLENDALE ROAD

ARLINGTON, TX 76011-4125

KING OF PRUSSIA, PA 19406-1415

PERSONS LOCATED IN AGREEMENT STATES SEND APPLICATIONS TO THE U.S. NUCLEAR REGULATORY COMMISSION ONLY IF THEY WISH TO POSSESS AND USE LICENSED

MATERIAL IN STATES SUBJECT TO U.S.NUCLEAR REGULATORY COMMISSION JURISDICTIONS.

1. THIS IS AN APPLICATION FOR (Check appropriate item)

2. NAME AND MAILING ADDRESS OF APPLICANT (Include ZIP code)

NEW LICENSE

AMENDMENT TO LICENSE NUMBER

RENEWAL OF LICENSE NUMBER

3. ADDRESS WHERE LICENSED MATERIAL WILL BE USED OR POSSESSED

4. NAME OF PERSON TO BE CONTACTED ABOUT THIS APPLICATION

TELEPHONE NUMBER

SUBMIT ITEMS 5 THROUGH 11 ON 8-1/2 X 11" PAPER. THE TYPE AND SCOPE OF INFORMAT ION TO BE PROVIDED IS DESCRIBED IN THE LICENSE APPLICATION GUIDE.

5. RADIOACTIVE MATERIAL

a. Element and mass number; b. chemical and/or physical form; and c. maiximum amount

6. PURPOSE(S) FOR WHICH LICENSED MATERIAL WILL BE USED.

which will be possessed at any one time.

7. INDIVIDUAL(S) RESPONSIBLE FOR RADIATION SAFETY PROGRAM AND THEIR

8. TRAINING FOR INDIVIDUALS WORKING IN OR FREQUENTING RESTRICTED AREAS.

TRAINING EXPERIENCE.

9. FACILITIES AND EQUIPMENT.

10. RADIATION SAFETY PROGRAM.

12. LICENSE FEES (See 10 CFR 170 and Section 170.31)

11. WASTE MANAGEMENT.

AMOUNT

FEE CATEGORY

ENCLOSED

13. CERTIFICATION. (Must be completed by applicant) THE APPLICANT UNDERSTANDS THAT ALL STATEMENTS AND REPRESENTATIONS MADE IN THIS APPLICATION ARE BINDING

UPON THE APPLICANT.

THE APPLICANT AND ANY OFFICIAL EXECUTING THIS CERTIFICATION ON BEHALF OF THE AP PLICANT, NAMED IN ITEM 2, CERTIFY THAT THIS APPLICATION IS PREPARED IN

CONFORMITY WITH TITLE 10, CODE OF FEDERAL REGULATIONS, PARTS 30, 32, 33, 34, 35 , 36, 39, AND 40, AND THAT ALL INFORMATION CONTANED HEREIN IS TRUE AND

CORRECT TO THE BEST OF THEIR KNOWLEDGE AND BELIEF.

WARNING: 18 U.S.C. SECTION 1001 ACT OF JUNE 25, 1948 62 STAT. 749 MAKES IT A C RIMINAL OFFENSE TO MAKE A WILLFULLY FALSE STATEMENT OR REPRESENTATION TO

ANY DEPARTMENT OR AGENCY OF THE UNITED STATES AS TO ANY MATTER WITHIN ITS JURIS DICTION.

CERTIFYING OFFICER -- TYPED/PRINTED NAME AND TITLE

SIGNATURE

DATE

FOR NRC USE ONLY

TYPE OF FEE

FEE LOG

FEE CATEGORY

AMOUNT RECEIVED

CHECK NUMBER

COMMENTS

APPROVED BY