NRC Form 831 Report of Export

NRC FORM 831

U.S. NUCLEAR REGULATORY COMMISSION APPROVED BY OMB: NO. 3150-0036

(MM-YYYY)
10 CFR 110.50

REPORT OF EXPORT

PRIOR NOTIFICATION OF
SHIPMENT OF CATEGORY 1 AND/OR 2
RADIOACTIVE SOURCES
In accordance with 10 CFR Part 110.50(b)(4) of the
U.S. NRC Regulations
A

EXPIRES: MM/DD/YYYY

Estimated burden per response to comply with this mandatory collection request: 30 minutes.
State here why and how NRC will use this information. 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, 3150-0036,
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.

SEND COMPLETED FORM TO:
U.S. Nuclear Regulatory Commission
ATTN: Headquarters Operation Center
Email: [email protected] (Preferred Reporting
Method)
Fax: (301) 415-2395 (Alternative Reporting Method)

Part 110 License Number:
Licensee Contact Information:
(Name & Phone Number)

B
U. S. Exporting Facility:
(Company Name, Address, City, State & Zip
Code)

C

D

Foreign Recipient Name, Address and End Use
Location(s) if different than Recipient's Address:

Radionuclide(s) and activity level in TBq, both
for single and aggregate shipments:
Total Activity Level (TBq):

E

Make, Model and Serial Number, for any
Category 1 or 2 Sealed Sources, if available:

F

End-use in the importing Country, if known:

G

Shipment Date: (MMDDYYYY)

H

This notification should be accompanied by a copy of the foreign recipient's
authorization or confirmation of that authorization from the government of the importing
country, as required by 110.32(h).

NRC Form 831 (M-YYYY)