Free Application for Material License, DPH 45022 - Wisconsin

DEPARTMENT OF HEALTH AND FAMILY SERVICES Division of Public Health DPH 45022 (02/04)

STATE OF WISCONSIN Bureau of Environmental Health Radiation Protection Section (608) 267-4797

APPLICATION FOR MATERIAL LICENSE
The Wisconsin Department of Health and Family Services is requesting disclosure of all information on this application for the purpose of obtaining a radioactive material license. Failure to provide information may result in denial or delay of a radioactive material license. Instructions ­ Complete all items. Use supplementary sheets if necessary. Retain a copy and submit the original of the entire application to the Department of Health and Family Services, P.O. Box 2659, Madison, WI 53701-2659. Telephone (608) 267-4797 Fax (608) 267-3695 Item 1. This is an Application For (check appropriate Item) A. New License B. Amendment to License Number ___________ C. Renewal of License Number______________ Item 2. Name and Mailing Address of Applicant (include Zip Code)

Item 3. Address Where Licensed Material Will Be Used Or Possessed

Item 4. Contact Person - Name

Item 5. Contact Person ­ Telephone Number (include area code)

Submit Items 6 Through 11 on 8-1/2 X 11' Paper. The Type and Scope of Information To Be Provided is Described in the License Application Guide

Item 6. Radioactive Material a. Element and mass number; b. chemical and/or physical form; and c. maximum amount Item 8. Individual(s) Responsible For Radiation Safety Program and Their Training Experience. Item 10. Facilities and Equipment. Item 12. Waste Management

Item 7. Purpose(s) For Which Licensed Material Will Be Used.

Item 9. Training For Individuals Working In or Frequenting Restricted Areas. Item 11. Radiation Safety Program Item 13. License Fees (See HFS 157.10) Fee Category Amount Enclosed $

CERTIFICATION (To be signed by an individual authorized to make binding commitments on behalf of the applicant.)
Item 14. I hereby certify that this application was prepared in conformance with Wisconsin Administrative Code, Chapter HFS 157 "Radiation Protection" and that all information contained herein, including any supplements attached hereto, is true and correct to the best of my knowledge and belief. SIGNATURE ­ Applicant or Authorized Individual Print Name and Title of above signatory Date signed