Form Doh-370 - Application For Radioactive Materials License
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3NEW YORK STATE DEPARTMENT OF HEALTH
APPLICATION FOR RADIOACTIVE MATERIALS LICENSE
[Applicants for licenses within New York City should contact the New York City
Department of Health, Bureau of Radiological Health, 2 Lafayette Street, 11th Floor,
New York, New York 10007 for application forms.]
Instructions: Complete Items 1-26. Use supplemental sheets where necessary.
Submit completed, dated, and signed application to:
New York State Department of Health
Bureau of Environmental Radiation Protection
Radioactive Materials Section
Flanigan Square – Room 530
547 River Street
Troy, New York 12180-2216
Upon approval of an application, the applicant will receive a “Radioactive Materials
License” issued pursuant to statutory authority, implementing regulatory authority, and
subject to all applicable rules, regulations, and orders of all regulatory agencies now or
hereafter in effect and to any conditions specified in the license.
1. a.
Name and Street Address of Applicant
1. b. Street Address(es) at which radioactive
(institution, hospital, firm, person, etc.)
material will be used (if different from 1.a.)
Administration
Telephone Number:
2.
Individual to be contacted about this
3.
This is an application for (check one):
“
application:
New License
“
Amendment to License No. _______
“
Telephone Number:
Renewal to License No. _______
4.
Radiation Safety Officer:
Telephone Number:
SUBMIT ITEMS 5 THROUGH 26 ON ADDITIONAL SHEETS (8 1/2" x 11")
(see appropriate license application guide)
5.
Individual Users.
6.
Radioactive Material (a) Element and mass number; (b) Chemical and physical form;
and (c) Maximum amount that will be possessed at any one time.
7.
Purpose(s) for which licensed material will be used.
8.
(a)
Individuals responsible for radiation safety program.
(b)
Radiation Safety Program/Committee.
9.
Training and Experience; Personnel Training Program.
10.
(a)
Instrumentation
(b)
Calibration
DOH-370 (7/99)
Page 1
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