NRC Form 313 APPLICATION FOR MATERIALS LICENSE

NRC FORM 313
(MM-DD-YYYY)
10 CFR 30, 32,
33, 34, 35, 36,
37, 39, and 40

U.S. NUCLEAR REGULATORY COMMISSION

APPLICATION FOR
MATERIALS LICENSE

EXPIRES: (MM/DD/YYYY)

APPROVED BY OMB: NO. 3150-0120

Estimated burden per response to comply with this mandatory collection request: 4.3 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 FOIA, Library, and Information Collections Branch (T-6 A10M), U.S. Nuclear
Regulatory Commission, Washington, DC 20555-0001, or by email to [email protected], and the OMB Reviewer
at: OMB Office of Information and Regulatory Affairs, (3150-0120), Attn: Desk Officer for the Nuclear Regulatory Commission,
725 17th Street NW, Washington, DC 20503; email: [email protected]. The NRC may not conduct or sponsor,
and a person is not required to respond to, a collection of information unless the document requesting or requiring the collection
displays a currently valid OMB control number.

INSTRUCTIONS: SEE THE CURRENT VOLUMES OF THE NUREG-1556 TECHNICAL REPORT SERIES (“CONSOLIDATED GUIDANCE ABOUT MATERIALS LICENSES”) FOR DETAILED
INSTRUCTIONS FOR COMPLETING THIS FORM: http://www.nrc.gov/reading-rm/doc-collections/nuregs/staff/sr1556/. SEND ONE COPY OF THE COMPLETED APPLICATION TO THE NRC
OFFICE SPECIFIED BELOW.
APPLICATION FOR DISTRIBUTION OF EXEMPT PRODUCTS FILE APPLICATIONS WITH:
MATERIALS SAFETY AND TRIBAL LIAISON BRANCH
DIVISION OF MATERIALS SAFETY, SECURITY, STATE AND TRIBAL PROGRAMS
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
DIVISION OF RADIOLOGICAL SAFETY AND SECURITY
U.S. NUCLEAR REGULATORY COMMISSION, REGION III
2443 WARRENVILLE ROAD, SUITE 210
LISLE, IL 60532-4352
[email protected]
*Note: The preferred method to submit NRC Form 313 is email. Any other document (e.g., financial
assurance documents) should be sent via mail.

ALL OTHER PERSONS FILE APPLICATIONS AS FOLLOWS:
IF YOU ARE LOCATED IN:
ALABAMA, CONNECTICUT, DELAWARE, DISTRICT OF COLUMBIA, FLORIDA,
GEORGIA, KENTUCKY, MAINE, MARYLAND, MASSACHUSETTS, NEW HAMPSHIRE,
NEW JERSEY, NEW YORK, NORTH CAROLINA, PENNSYLVANIA, PUERTO RICO,
RHODE ISLAND, SOUTH CAROLINA, TENNESSEE, VERMONT, VIRGINIA, VIRGIN
ISLANDS, OR WEST VIRGINIA,

IF YOU ARE LOCATED IN:
ALASKA, ARIZONA, ARKANSAS, CALIFORNIA, COLORADO, HAWAII, IDAHO, KANSAS,
LOUISIANA, MISSISSIPPI, MONTANA, NEBRASKA, NEVADA, NEW MEXICO, NORTH
DAKOTA, OKLAHOMA, OREGON, PACIFIC TRUST TERRITORIES, SOUTH DAKOTA, TEXAS,
UTAH, WASHINGTON, OR WYOMING,

SEND APPLICATIONS TO:
LICENSING ASSISTANCE TEAM
DIVISION OF RADIOLOGICAL SAFETY AND SECURITY
U.S. NUCLEAR REGULATORY COMMISSION, REGION I
475 ALLENDALE ROAD, SUITE 102
KING OF PRUSSIA, PA 19406-1415
[email protected]
*Note: The preferred method to submit NRC Form 313 is email. Any other document (e.g.,
financial assurance documents) should be sent via mail.

SEND APPLICATIONS TO:
MATERIALS LICENSING BRANCH
DIVISION OF RADIOLOGICAL SAFETY AND SECURITY
U.S. NUCLEAR REGULATORY COMMISSION, REGION IV
1600 E. LAMAR BOULEVARD
ARLINGTON, TX 76011-4511
[email protected]
*Note: The preferred method to submit NRC Form 313 is email. Any other document (e.g., financial
assurance documents) should be sent via mail.

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

1. THIS IS AN APPLICATION FOR (Check appropriate item)
A. NEW LICENSE
B. AMENDMENT TO LICENSE NUMBER
C. RENEWAL OF LICENSE NUMBER
3. LIST ADDRESS AND/OR TEMPORARY JOB SITE (TJS) ADDRESS, WHERE LICENSED
MATERIALS WILL BE USED OR POSSESSED

4. NAME OF PERSON TO BE CONTACTED ABOUT THIS APPLICATION

BUSINESS TELEPHONE NUMBER

BUSINESS CELLULAR TELEPHONE NUMBER

BUSINESS E-MAIL ADDRESS

SUBMIT ITEMS 5 THROUGH 11 ON 8-1/2 X 11" PAPER. THE TYPE AND SCOPE OF INFORMATION TO BE PROVIDED IS DESCRIBED IN THE LICENSE APPLICATION GUIDE.
5. RADIOACTIVE MATERIAL
6. PURPOSE(S) FOR WHICH LICENSED MATERIAL WILL BE USED.
a. Element and mass number; b. chemical and/or physical form; and c. maximum amount
which will be possessed at any one time.
8. TRAINING FOR INDIVIDUALS WORKING IN OR FREQUENTING RESTRICTED AREAS.
10. RADIATION SAFETY PROGRAM.

7. INDIVIDUAL(S) RESPONSIBLE FOR RADIATION SAFETY PROGRAM AND THEIR TRAINING AND
EXPERIENCE.
9. FACILITIES AND EQUIPMENT.
11. WASTE MANAGEMENT.

12. LICENSE FEES (Fees required only for new applications, with few exceptions*)
FEE
(See 10 CFR 170 and Section 170.31)
CATEGORY
*Amendments/Renewals that increase the scope of the existing license to a new or higher fee category will require a fee.

AMOUNT
ENCLOSED

$

PER THE DEBT COLLECTION IMPROVEMENT ACT OF 1996 (PUBLIC LAW 104-134), YOU ARE REQUIRED TO PROVIDE YOUR TAXPAYER IDENTIFICATION NUMBER. PROVIDE THIS
INFORMATION BY COMPLETING NRC FORM 531: https://www.nrc.gov/reading-rm/doc-collections/forms/nrc531info.html. FAX THE COMPLETED NRC FORM 531 TO (301) 415-6725.
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 APPLICANT, 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, 37, 39, AND 40, AND THAT ALL INFORMATION CONTAINED 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 CRIMINAL OFFENSE TO MAKE A WILLFULLY FALSE STATEMENT OR REPRESENTATION TO
ANY DEPARTMENT OR AGENCY OF THE UNITED STATES AS TO ANY MATTER WITHIN ITS JURISDICTION.
SIGNATURE

CERTIFYING OFFICER -- TYPED/PRINTED NAME AND TITLE

FOR NRC USE ONLY
TYPE OF FEE

FEE LOG

APPROVED BY
NRC FORM 313 (MM-DD-YYYY)

FEE CATEGORY

$

AMOUNT RECEIVED

CHECK NUMBER COMMENTS
DATE

DATE