Dh 1322 - Application For Radioactive Materials License

ADVERTISEMENT

FLORIDA DEPARTMENT OF HEALTH
RADIOACTIVE MATERIALS SECTION
APPLICATION FOR RADIOACTIVE MATERIALS LICENSE
HUMAN USE
INSTRUCTIONS - Complete Items 1 – 35 as applicable. Item 35 must be completed on all applications.
Use supplemental sheets where necessary. Mail the original and one copy to: Department of Health, Bureau
of Radiation Control, Radioactive Materials Section, 4052 Bald Cypress Way, Bin #C21, Tallahassee, FL
32399-1741. Regulatory Guidance Documents are available from the Bureau of Radiation Control to assist in
completing this application.
1.a. LEGAL NAME, MAILING ADDRESS
1.b. STREET ADDRESS WHERE
(Include ZIP code), FEI #, Phone & Fax Numbers:
RADIOACTIVE MATERIALS WILL BE
USED OR STORED (Include ZIP Code)
Same as 1.a.
FEI #_____________________________________
Telephone # _______________________________
Fax # ____________________________________
2.a.
LICENSE FEE CATEGORY
3. THIS IS AN APPLICATION FOR:
(See 64E-5.204, F.A.C., for license descriptions)
a. New License
______________
b. Amendment To License Number:_______
c. Renewal Of License Number:__________
b. LICENSE FEE ENCLOSED: $________________
4.
INDIVIDUAL USERS & REQUESTED USES
5.a. RADIATION SAFETY OFFICER (RSO):
(Name all Authorized Users & Authorized Medical
(Name and Contact Information)
Physicists, who may receive, possess, prepare, use or
Name: ______________________________
transfer radioactive materials or directly supervise others
in these activities.)
RSO Phone #:________________________
SEE ATTACHED LIST
RSO E-Mail: _________________________
5.b. ALTERNATE EMERGENCY CONTACT:
Name: ______________________________
Contact Phone #: _____________________
Contact E-Mail: _______________________
DH 1322,12/09 (Rule 64E-5.207, F.A.C.)
Page 1 of 4

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Business
Go
Page of 4