Form DA From 3337 DA From 3337 APPLICATION FOR ARMY RADIATION AUTHORIZATION

APPLICATION FOR ARMY RADIATION AUTHORIZATION
For use of this form, see DA Pamphlet 385-24; the proponent agency is DAS.

0702-0109
Expiration Date:
XXXXXXXX

The public reporting burden for this collection of information, 0702-0109, is estimated to average 2 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data
needed, and completing and reviewing the collection of information. Send comments regarding the burden estimate or burden reduction suggestions to the Department of Defense, Washington Headquarters Services, at [email protected]. Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does
not display a currently valid OMB control number.

1. THIS IS AN APPLICATION FOR (Check appropriate item)

2. NAME, MAILING ADDRESS, AND E-MAIL ADDRESS OF APPLICANT
(Include ZIP Code)

NEW ARA
AMENDMENT TO ARA NUMBER
RENEWAL OF ARA NUMBER

3. ADDRESSES WHERE AUTHORIZED IONIZING RADIATION SOURCES WILL BE USED OR POSSESSED

4. NAME OF PERSON TO BE CONTACTED ABOUT THIS APPLICATION

5. TELEPHONE NUMBER AND FAX NUMBER

Items 6 through 12 may be continued on the following page or on 8 1/2 x 11 inch paper. The type and scope of
information to be provided should be adequate to show complete compliance with applicable regulations and
guidance. (If you can link use of radioactive material to a valid Nuclear Regulatory Commission (NRC) license,
provide number and expiration date of the license and only submit items that differ from the NRC license
application and associated documents.)
6. RADIATION SOURCE(s)
a. RADIOACTIVE MATERIAL (Element and mass number, chemical
and/or physical form, and maximum amount that you will possess at
any one time.)

b. ACCELERATOR(s) AND X-RAY SYSTEM(s) CAPABLE OF
PRODUCING A "HIGH RADIATION AREA" OR "VERY HIGH RADIATION
AREA" (Describe)

7. PURPOSE(s) FOR WHICH IONIZING RADIATION SOURCE(s) WILL
BE USED

8. INDIVIDUAL(s) RESPONSIBLE FOR RADIATION SAFETY PROGRAM
AND THEIR TRAINING AND EXPERIENCE

9. TRAINING FOR INDIVIDUALS WORKING IN OR FREQUENTING
RESTRICTED AREAS

10. FACILITIES AND EQUIPMENT (Describe rooms or areas, sheidling,
safety devices, monitoring equipment, and so on.)

11. RADIATION SAFETY PROGRAM

12. WASTE MANAGEMENT

13. CERTIFICATION

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 applicant, named in Item 2, certify that all
information contained in this application is true and correct to the best of their knowledge and belief.
14. NAME, RANK, AND TITLE OF CERTIFYING OFFICER

15. SIGNATURE

16. DATE (YYYYMMDD)

DA FORM 3337, SEP 2011

PREVIOUS EDITIONS ARE OBSOLETE.

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APD LC v1.00ES

ITEMS 6 THRU 12 (Continued)

DA Form 3337, SEP 2011

PREVIOUS EDITIONS ARE OBSOLETE

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