Radioactive Materials Declaration Form

Applicant Information

Full Name

Department/Unit

Contact Number

Email Address

Radioisotope	Form (solid, liquid, gas)	Quantity	Activity (Bq/Ci)	Packing/Container Type	Purpose of Use

Storage Location

Storage Method

Transport Method

From (Location)

To (Location)

Date of Transport

Briefly describe the disposal plan:

I hereby declare that the information provided above is true and correct to the best of my knowledge.

Declarant Name

Date