NRC Form 831A Report of Export Continuation Sheet

10 CFR Part 110, Export and Import of Nuclear Equipment and Material

NRC 831A (PS)

10 CFR 110 Part 110, Export and Import of Nuclear Equipment and Material

OMB: 3150-0036

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NRC FORM 831A
(MM-YYYY)
10 CFR 110.50(c)(3)(i)

U.S. NUCLEAR REGULATORY COMMISSION

REPORT OF EXPORT
CONTINUATION SHEET
ADVANCED NOTIFICATION OF
SHIPMENT OF CATEGORY 1 AND/OR 2
RADIOACTIVE SOURCES

In accordance with 10 CFR Part 110.50(c)(3)(ii)
of the U.S. NRC Regulations

Reference Number:

APPROVED BY OMB: NO. 3150-0036

EXPIRES: (MM/DD/YYYY)

Estimated burden per response to comply with this mandatory collection request: 30 minutes.
This form allows the NRC to request additional information from licensees to determine whether a
license should be revoked, suspended, or modified. Send comments regarding burden estimate
to the FOIA, Privacy, and Information Collections Branch (T-5 F53), U.S. Nuclear Regulatory
[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) 816-5151 (Alternative Reporting Method)

Part 110 License Number:
Expiration Date of Part 110 License Number:
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NRC Form 831A (MM-YYYY)

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