Name_________________________Address_______________________________Dept._____________

Building_______________________Lab(s)________________________Telephone No.____________

Describe your educational background, training and experience, as relates to working with the radioisotopes indicated for approval. Use additional page if necessary.

III. Previous License (if formerly licensed at another institution)

________________________________________________________________________________________

IV. Have radiation exposure records been maintained for you at another institution? If yes, indicate the address where these records may be obtained and the dates these records cover.

(a) Radioisotopes to be used: Include maximum amounts of each you wish to possess.

(b) Briefly describe the proposed use. (Include estimated typical amounts used at any one time in your experiment.) Use additional sheets if necessary.

(c) Describe training and instructions that the actual users of radioisotopes will be given.

As a Sublicensee, I may apply for amendment to my sublicense for approval of an Authorized Representative. I understand the role of a 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.

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

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

I understand that approval of this application limits my use of radioactive materials to the isotopes specified. I have read and I will abide by the University of Alabama Environmental Health and Safety - Radiation Safety Manual.

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