FORM NO. 5-A

Pakistan Nuclear Regulatory Authority

P. O. Box No. 1912, Islamabad.

APPLICATION FORM FOR REGISTRATION OF THE PREMISES AND LICENSING OFNUCLEAR GAUGES USED FOR INDUSTRIAL APPLICATIONS

1.Particulars of the applicant (attach copy of the C.N.I.C)

Name: / CNIC No.
Title(Owner, Director, etc):
Address: / Tele. No.:
Fax No.
e-mail:

2. If applicant is not the owner, particulars of the owner.

Name: / CNIC No.
Address: / Tele. No.:
Fax No.
e-mail:
  1. Have you ever applied for registration/licensing with PNRA in the pastYes No

If yes

  1. In which office of PNRA you applied for registration/licensing

Islamabad KundianKarachi

  1. When you applied for registration/licensing(dd:mm:yy)
  2. What was the final decision of PNRA on your application (Please give brief description)……………………………………………………………………………………………………………………………………………………………………………………….………………………………………………………………………………………………….

4.If already licensed with PNRA, then what is current status of your license?

Valid Suspended Revoked

5. Purpose for which licence is required

6.Gauge Type:MobileFix

7.Location ofradiationfacility

Name of organization/industry:
Address (including Tehsil, District):
Premises Owned or on Lease (attach documents)
  1. In case of fixed gauge attach the sketch of the area where the gauge is installed

Yes No 

9.Particulars of nuclear gauge (s):

Manufacturer / Gauge Model
Number / Sealed Source Identification
Number / Radionuclide / Source
Supplier / Maximum
Activity / Radiation Type / Number of
Gauges / Date of acquisition
  1. Particulars of radiation workers/ Radiation Protection Officer (RPO)

Sr.
No. / Name / Age / Qualification / Experience/Training

11.Is the Nuclear Gauge manufactured, prototype tested, and subject to quality control provisions of standards recognized by national or international standard setting organizations (e.g. IEC) If, so please identify the standards and any applicable classification numbers.

______

______

12.Arrangements for personal dose monitoring from dosimetery services (PINSTECH, P. O. Nilore, Islamabad/ KIRAN Hospital, Near Safoora Goth, KDA Scheme-33 Gulzar-e-Hijri, Karachi)

a.FilmTLDb.Whole BodyExtremity

c.Supplier...... ,d. Frequency of Exchange......

13.Detail of available Personal Protective Equipments (PPE).

………………………………………………………………………………………………………………………………………………………………………………………………………………………………

14.Radiation monitoring instrument (s)

Type of Instrument (including manufacturer and Model number of each) / Number Instrument(s)
Available / Radiation
Detected / SensitivityRange
(R/hr)/ (Sv/hr) / Use (monitoring, survey etc) / Calibration
Status

15.Arrangements for Security of Nuclear Gauge (s)

………………………………………………………………………………………………………………………………………………………………………………………………………………………………

16.Detail of radiation protection program as appropriate for the material to be used, including general radiation safety procedures, emergency procedures etc.

…………………………………………………………………………………………………………………………………………………………………………………………………………………………

17.Arrangements for the radioactive waste management

………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

18.Particulars of Pay Order/Bank Draft as licence fee in favor of “Director Finance PNRA, Islamabad”including:-

Pay Order/Bank Draft Number………………………………………….

Amount……………………………………………………………………..

Date…………………………………………………………………………

Name of the Bank…………………………………………………………

19.Date of commencement of operation:

I, hereby, affirm that all the particulars given above are correct to the best of my knowledge and belief and I undertake to abide by the provisions of PNRA Ordinance- 2001, Regulations for the Licensing of Radiation Facility (ies) other than Nuclear Installation(s) - PAK/908, Regulations on Radiation Protection - PAK/904 and any other conditions imposed by the Authority from time to time including any guidelines or amendments/revisions issued thereto.

Signature of the Owner ______Signature of the applicant ______

Dated: ______Dated: ______

Seal of Office ______

Please check the following:-

i.Copy of C.N.I. Card attached YesNo

ii. Ownership/Lease documents attached YesNo

iii.Sketch of gauge installed area attached YesNo

iv.Pay order/bank draft attached. Yes No

(For details please contact your respective RNSD).

RNSD-I, Islamabad 051-9263019, RNSD-II, Kundian 0459-924294, RNSD-III, Karachi 021-9266282

Instruction: Use supplemental sheets where necessary. Mail the completely filled application form along with all relevant documents to the concerned “Regional Nuclear Safety Directorate”.

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