Telephone Fax No.

: :

022 555 2994 / 557 2995 022 556 2344 / 5562717

AERB/RSD/IR/IU-1

Government of India Atomic Energy Regulatory Board Radiological Safety Division Application for Authorization to procure Use Industrial Radiography Sources / Equipments. 1. Name and address of the institution (Kindly attach a copy of the registration Document of the institute) Telephone No. Fax No. 2. Name of the Head of the institution Telephone No. Fax No. : : : : :

3. Details of Institution where Radiography source will be used Name, Location & Address of Institute Telephone No. Name & Designation of the head of the Institution Telephone No.(Office) Telephone No.(Resi.) : : : :

(a) name of the Individual who is entrusted : with the responsibility for the radiography source and radiation safety in the institution. 4. (a) Name and address of the person to be contact in case of emergency. Telephone No. : :

(b). Are the person doing radiation work : covered by Personal Monitoring Service? If yes (i) Give details : If no (ii) Contact Head, Personal Monitoring Section RS&ID, BARC, Mumbai-400085 OR Head, Radiological Physics & Advisory Division, CT & CRS Building, BARC,Mumbai400 094 For starting the service

This Form is meant only to assess the suitability of an applicant for carrying out radiography work & should not be construed as a purchase order.