Radioactive Material Declaration
1. General Information
Organization Name
Address
Contact Person
Contact Number
Email
2. Material Details
Radionuclide
Form
Activity (Bq or Ci)
Quantity
Purpose of Use
Physical State
Solid
Liquid
Gas
Storage Location
3. Declaration
I hereby certify that the above information is true and complete to the best of my knowledge.
Declarer's Name
Position
Date