Board of Radiation & Isotope Technology

Government of India, Department of Atomic Energy SA-4 form, SINGLE COPY ONLY

Customer Code C -Standing Order application form for Radiopharmaceutical products

1. Name & Full Address of Applicant (See Note 1) 2. To. Be invoiced to

Name &
Designation
Department
Institution
Address

City, PIN
Phone No.(with STD Code) Fax: Phone No.(with STD Code) Fax:

Email : Email:
Mobile No:
Airport

3. Mode of supply i) PC/Pd ii) Speed Post (for RIA only PC/PD iii) Air
4.List Of Radiopharmaceuticals required.( Maximum five products in one application form for 10M,TCM,TCK,RIA products)

Product Cord Quantity (Activity Supply Remark If Any Purpose of Order registration
in mCi,or No. of Frequency regarding supply Use reference number
kits (For office use only)
1
2
3
4
5
Supply Frequency 1. Weekly 2. Twice a month 3. Monthly 4. Once in two months 5. Quarterly
Purpose of Use A.Om Humans in-vivo/in-vitro b. For investigations on Animals/Research C. Others

5. If this application is to be regarded as a purchase
orders for the materials to which it refers subject to
the conditions of supply listed overleaf.
Signature of the person authorized to sign the
6. I undertake to ensure that any materials supplied against
this application will not be used otherwise than described
above I undertake full responsibility when the material is
Used on human beings. I have read the explanatory notes
O & conditions of supply given overleaf.

Purchase order on behalf of above institution

Date Signature of the Applicant

Name & Designation Date

Purchase Order Number & Date

 See Explanatory Notes

Address: BRIT Vashi Complex, Sector-20, Vashi Mumbai-400 703 Telephone No-022-27887254 Fax No-022-27887272/18
E-Mail IId-rphp@britatom.gov.in /dryojanasingh@gmail.com, Website: - www.britatom.gov.in