I, (name of user)_________________________________________ have agreed to terminate my dosimetry use at the UA.

Please send exposure history to the following address:

Reason for termination ___________________________________________________________

Signature of user ________________________________________ Date ___________________

The individual submitting this request is no longer working with radioactive material or radiation producing machines under my supervision.

Signature of Sublicensee ____________________________________ Date ________________

Date Activated: _________ Types ________________________ Visitor # _____________

Date Deactivated:_________ Previous Exposure __________________________________

Dosimetry control number(s) __________________________________________________