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Forms / Postings


All  |  General Licenses  |  Specific License


Forms / Postings Useful for all types of Licenses

Notice to Employees 

Occupational Exposure Record  

Cumulative Occupational Exposure History 

Certificate of Disposition of Materials  

Reciprocity Privileges Checklist  

 

Forms / Postings Useful for General Licenses

Pertaining to Use of Depleted Uranium Under a General License      

 


Forms / Postings Useful for Specific Licenses

INITIAL APPLICATIONS

Please submit the initial application electronically to either RADMAT or Mike Welling. The application should either be signed and scanned in as a pdf or be sent as a word document and include an electronic signature. The application fee can either be paid by check with the application or by credit card. Please refer to the "Fee Schedule Page" for viewing the fee schedule and a link to pay on-line.

Initial Portable Gauge Application

Initial XRF Application

Initial Fixed Gauge Application

Initial Medical Application

Initial Radiopharmacies Application

Initial Radiography Application

Initial Irradiator Application

Initial Broad Scope Application

Initial Specific Licensee Application

Initial Sealed Source Application

Initial Well Logging Application


RENEWAL APPLICATIONS

Please submit the initial application electronically to either RADMAT or Mike Welling. The application should either be signed and scanned in as a pdf or be sent as a word document and include an electronic signature.

Portable Gauge Renewal Application

XRF Renweal Application

Fixed Gauge Renewal Application

Medical Renewal Application

Radiopharmacies Renewal Application

Radiography Renewal Application

Irradiator Renewal Application

Broad Scope Renewal Application

Specific Licensee/R&D Renwewal Application

Sealed Source Renewal Application

Well Logging Renewal Application


 

Training, Experience and Preceptor Attestations

  • Attestation-A, (Radiation Safety Officer For Medical Use)

  • Attestation-B, (Authorized User -Written Directive Not Required)

  • Attestation-C, (Unsealed Radioactive Material Requiring A Written Directive)

  • Attestation-D, (Authorized User For Manual Brachytherapy Sources)

  • Attestation-E, (Authorized User Of Remote Afterloader, Teletherapy Or Gamma Stereotactic Radiosurgery Units)

  • Attestation-F, (Authorized Medical Physicist)

  • Attestation-G, (Authorized Nuclear Pharmacist)


  • Forms Useful for scrap/trash


    DOT-1056 Exemption for scrap loads

DOT-11406 Exemption for trash loads

 

Office of Radiological | James Madison Building, 7th Floor | 109 Governor Street,  7th Floor | Richmond, VA  23219 | Telephone (804) 864-8150 | Fax: (804) 864-8155


Last Updated: 01-07-2016

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