APPLICATION FOR APPROVAL OF AN AUTHORIZED REPRESENTATIVE

Sublicensee____________________________ Lic. # __________ Dept ____________

Box # _____________ Lab(s)_________________________________________

Sublicense type: Unsealed source ____ Sealed source ____X-ray ____

As a Sublicensee, I may apply for amendment to my sublicense for approval of an Authorized Representative. I understand the role of an Authorized Representative is to act on the behalf of the Sublicensee. The signing of forms, performing contamination surveys, submitting monthly Radioactive Materials inventories, attending Radiation Safety meetings or any duties normally performed by the Sublicensee may be delegated to the Authorized Representative. However, actions taken by the Authorized Representative do not alleviate sublicensee responsibilities. As Sublicensee I am responsible for compliance with Radiation Safety guidelines and regulations.

Name ___________________________ SS# _________________ Phone # _________________

Address _________________________Status _____________ Dept. _______________

Supervisor _____________________________

II. Education/experience/training - Describe the education, experience and training of the proposed Authorized Representative in relation to your type of sublicense.

III. Extent of responsibility - Describe the circumstances under which you need the services of an Authorized Representative. For example, are you frequently away from campus or unavailable.

Signature of sublicensee applicant _________________________________ Date ___________

This amendment is accepted for consideration and is subject to approval by the RSO and the RCAC.

Decision for (Check one): Approval _____ Rejection _____

Signature of RSO __________________________________ Date _____________