Form NRC Form 313 NRC Form 313 Application for Material License

NRC FORM 313

U.S. NUCLEAR REGULATORY COMMISSION APPROVED BY OMB: NO. 3150-0120

(MM-YYYY)
10 CFR 30, 32, 33,
34, 35, 36, 39, and 40

APPLICATION FOR MATERIAL LICENSE

EXPIRES: MM/DD/YYYY
Estimated burden per response to comply with this mandatory collection request: 7
hours. Submittal of the application is necessary to determine that the applicant is
qualified and that adequate procedures exist to protect the public health and safety.
Send comments regarding burden estimate to the Records and FOIA/Privacy Services
Branch (T-5 F53), U.S. Nuclear Regulatory Commission, Washington, DC 20555-0001,
or by internet e-mail to [email protected], and to the Desk Officer, Office of
Information and Regulatory Affairs, NEOB-10202, (3150-0120), Office of Management
and Budget, Washington, DC 20503. If a means used to impose an information
collection does not display a currently valid OMB control number, the NRC may not
conduct or sponsor, and a person is not required to respond to, the information
collection.

INSTRUCTIONS: SEE THE APPROPRIATE LICENSE APPLICATION GUIDE FOR DETAILED INSTRUCTIONS FOR COMPLETING APPLICATION.
SEND TWO COPIES OF THE ENTIRE COMPLETED APPLICATION TO THE NRC OFFICE SPECIFIED BELOW.
APPLICATION FOR DISTRIBUTION OF EXEMPT PRODUCTS FILE APPLICATIONS WITH:
DIVISION OF INDUSTRIAL AND MEDICAL NUCLEAR SAFETY
OFFICE OF NUCLEAR MATERIALS SAFETY AND SAFEGUARDS
U.S. NUCLEAR REGULATORY COMMISSION
WASHINGTON, DC 20555-0001

IF YOU ARE LOCATED IN:
ILLINOIS, INDIANA, IOWA, MICHIGAN, MINNESOTA, MISSOURI, OHIO, OR WISCONSIN, SEND
APPLICATIONS TO:
MATERIALS LICENSING BRANCH
U.S. NUCLEAR REGULATORY COMMISSION, REGION III
2443 WARRENVILLE ROAD, SUITE 210
LISLE, IL 60532-4352

ALL OTHER PERSONS FILE APPLICATIONS AS FOLLOWS:
IF YOU ARE LOCATED IN:
ALABAMA, CONNECTICUT, DELAWARE, DISTRICT OF COLUMBIA, FLORIDA, GEORGIA,
KENTUCKY, MAINE, MARYLAND, MASSACHUSETTS, MISSISSIPPI, NEW HAMPSHIRE, NEW
JERSEY, NEW YORK, NORTH CAROLINA, PENNSYLVANIA, PUERTO RICO, RHODE
ISLAND, SOUTH CAROLINA, TENNESSEE, VERMONT, VIRGINIA, VIRGIN ISLANDS, OR
WEST VIRGINIA, SEND APPLICATIONS TO:
LICENSING ASSISTANCE TEAM
DIVISION OF NUCLEAR MATERIALS SAFETY
U.S. NUCLEAR REGULATORY COMMISSION, REGION I
475 ALLENDALE ROAD
KING OF PRUSSIA, PA 19406-1415

ALASKA, ARIZONA, ARKANSAS, CALIFORNIA, COLORADO, HAWAII, IDAHO, KANSAS,
LOUISIANA, MONTANA, NEBRASKA, NEVADA, NEW MEXICO, NORTH DAKOTA, OKLAHOMA,
OREGON, PACIFIC TRUST TERRITORIES, SOUTH DAKOTA, TEXAS, UTAH, WASHINGTON,
OR WYOMING, SEND APPLICATIONS TO:

NUCLEAR MATERIALS LICENSING BRANCH
U.S. NUCLEAR REGULATORY COMMISSION, REGION IV
611 RYAN PLAZA DRIVE, SUITE 400
ARLINGTON, TX 76011-4005

PERSONS LOCATED IN AGREEMENT STATES SEND APPLICATIONS TO THE U.S. NUCLEAR REGULATORY COMMISSION ONLY IF THEY WISH TO POSSESS AND USE LICENSED
MATERIAL IN STATES SUBJECT TO U.S.NUCLEAR REGULATORY COMMISSION JURISDICTIONS.
1. THIS IS AN APPLICATION FOR (Check appropriate item)
A.

NEW LICENSE

B.

AMENDMENT TO LICENSE NUMBER

C.

RENEWAL OF LICENSE NUMBER

2. NAME AND MAILING ADDRESS OF APPLICANT (Include ZIP code)

3. ADDRESS WHERE LICENSED MATERIAL WILL BE USED OR POSSESSED

4. NAME OF PERSON TO BE CONTACTED ABOUT THIS APPLICATION

TELEPHONE NUMBER

SUBMIT ITEMS 5 THROUGH 11 ON 8-1/2 X 11" PAPER. THE TYPE AND SCOPE OF INFORMAT ION TO BE PROVIDED IS DESCRIBED IN THE LICENSE APPLICATION GUIDE.
5. RADIOACTIVE MATERIAL
a. Element and mass number; b. chemical and/or physical form; and c. maiximum amount
which will be possessed at any one time.

6. PURPOSE(S) FOR WHICH LICENSED MATERIAL WILL BE USED.

7. INDIVIDUAL(S) RESPONSIBLE FOR RADIATION SAFETY PROGRAM AND THEIR
TRAINING EXPERIENCE.

8. TRAINING FOR INDIVIDUALS WORKING IN OR FREQUENTING RESTRICTED AREAS.

9. FACILITIES AND EQUIPMENT.

10. RADIATION SAFETY PROGRAM.
12. LICENSE FEES (See 10 CFR 170 and Section 170.31)

11. WASTE MANAGEMENT.

AMOUNT
$
FEE CATEGORY
ENCLOSED
13. CERTIFICATION. (Must be completed by applicant) THE APPLICANT UNDERSTANDS THAT ALL STATEMENTS AND REPRESENTATIONS MADE IN THIS APPLICATION ARE BINDING
UPON THE APPLICANT.
THE APPLICANT AND ANY OFFICIAL EXECUTING THIS CERTIFICATION ON BEHALF OF THE AP PLICANT, NAMED IN ITEM 2, CERTIFY THAT THIS APPLICATION IS PREPARED IN
CONFORMITY WITH TITLE 10, CODE OF FEDERAL REGULATIONS, PARTS 30, 32, 33, 34, 35 , 36, 39, AND 40, AND THAT ALL INFORMATION CONTANED HEREIN IS TRUE AND
CORRECT TO THE BEST OF THEIR KNOWLEDGE AND BELIEF.
WARNING: 18 U.S.C. SECTION 1001 ACT OF JUNE 25, 1948 62 STAT. 749 MAKES IT A C RIMINAL OFFENSE TO MAKE A WILLFULLY FALSE STATEMENT OR REPRESENTATION TO
ANY DEPARTMENT OR AGENCY OF THE UNITED STATES AS TO ANY MATTER WITHIN ITS JURIS DICTION.
CERTIFYING OFFICER -- TYPED/PRINTED NAME AND TITLE

SIGNATURE

DATE

FOR NRC USE ONLY
TYPE OF FEE

FEE LOG

FEE CATEGORY

AMOUNT RECEIVED

CHECK NUMBER

COMMENTS

$
APPROVED BY

NRC FORM 313 (MM-YYYY)

DATE

PRINTED ON RECYCLED PAPER