Application For Radioactive Materials License - North Carolina Radioactive Materials Branch
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1NORTH CAROLINA
(RMB USE ONLY)
RADIOACTIVE MATERIALS BRANCH
D
RADIATION PROTECTION SECTION
LN
APPLICATION FOR RADIOACTIVE MATERIALS LICENSE
R
INSTRUCTIONS:
Complete Items 1 through 5, using additional sheets as necessary. Refer to the appropriate licensing guide for information that MUST
accompany this completed application form. Item 5 MUST be completed on all applications. E-Mail ONE copy of this application and copies of all
supporting information to: LICENSING.RAM@DHHS.NC.GOV. Upon approval of the complete application, the applicant will receive a Radioactive
Materials License issued in accordance with the requirements contained in Chapter 104E of the North Carolina General Statutes and Title 10A, Chapter 15, of
the North Carolina Administrative Code.
1a.
LEGAL BUSINESS NAME AND MAILING ADDRESS OF
1b. PHYSICAL
ADDRESS(ES)
AT
WHICH
THE
RADIOACTIVE
APPLICANT
MATERIAL WILL BE USED OR POSSESSED
1c.
CHECK THIS BOX IF TEMPORARY JOB SITES ARE NEEDED:
2.
RADIATION SAFETY OFFICER:
3.
INDIVIDUAL TO BE CONTACTED ABOUT THIS APPLICATION
Name
Name
Phone No.
Phone No.
e-mail addr.
e-mail addr.
4.
CHECK THE TYPE AND CATEGORY OF LICENSE YOU ARE APPLYING FOR:
THIS IS AN APPLICATION FOR A:
NEW LICENSE OR
RENEWAL OF
TYPE (check one only)
MEDICAL *
§
INDUSTRIAL/NON-MEDICAL
ACADEMIC
§
§
CATEGORIES (check one only)
BROAD SCOPE
PORTABLE NUCLEAR GAUGE
SERVICE/CONSULTANT
HOSPITAL-BASED
FIXED NUCLEAR GAUGE
MANF. and/or DISTRIBUTION
NON-HOSPITAL BASED (R&D, lab, etc.)
INDUSTRIAL RADIOGRAPHY
IRRADIATOR (including panoramic)
OTHER (describe)
VETERINARY (non-human medical use)
*
Medical means that the radioactive materials will be used by physicians in the treatment or diagnosis of disease in humans
You may be subject to 10A NCAC 15 .1700 requirements if you possess the types and quantities of material shown in Appendix A to 10 CFR Part 37
§
IN ORDER TO COMPLETE THIS LICENSE APPLICATION YOU NEED TO SUBMIT ALL SUPPORTING INFORMATION
CERTIFICATION
(MUST be completed by the applicant before this application can be processed by the agency)
5.
THE APPLICANT AND ANY OFFICIAL EXECUTING THIS CERTIFICATE ON BEHALF OF THE APPLICANT NAMED IN ITEM 1,
CERTIFY THAT ALL INFORMATION CONTAINED HEREIN, INCLUDING ANY SUPPLEMENTS ATTACHED HERETO, HAS BEEN
PREPARED IN CONFORMITY WITH ALL APPLICABLE NORTH CAROLINA LAWS AND REGULATIONS AND IS TRUE AND
CORRECT TO THE BEST OF OUR KNOWLEDGE AND BELIEF.
BY:
Signature of Certifying Official
Date Signed
Printed Name and Title of Certifying Official
FOR RPS USE ONLY
Comments:
Revised August 2016
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