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.
I. Proposed Authorized Representative
Name ___________________________ CWID# _________________ Phone # _________________
Address _________________________ Status _____________ Dept. _______________
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 _____________