FORM NO. 1-A

Pakistan Nuclear Regulatory Authority

P. O. Box No. 1912, Islamabad.

APPLICATION FORM FOR REGISTRATION OF THE PREMISES AND LICENSING OF DIAGNOSTIC RADIATION APPARATUS

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:

3.  Have you ever applied for registration/licensing with PNRA in the past Yes No

If yes

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

Islamabad Kundian Karachi

b.  When you applied for registration/licensing (dd:mm:yy)

c.  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. Location of Radiation Apparatus

Address (including Tehsil &District):

6.  Attach the sketch of the radiation apparatus room including Yes No

i.  Doors and windows

ii.  Thickness and material of walls

iii. Shielded points of room along with the thickness of shielding material

iv.  Minimum distance of walls, roof, floor from X-ray target of the machine.

v.  Position of control panel, chest stand and dark room.

vi.  Rooms/area adjacent to radiation apparatus room and their occupancy

7. Detail of available Personal Protective Equipments (PPE) (e.g. lead apron, lead gloves etc).

……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….8. Detail of available Radiation Monitoring Equipments (if any)

………………..…......

9. Specification of Radiation Apparatus

Sr.
No. / Model/Make / ID. No. of X-ray Tube & Serial No. Of Control Panel / Maximum Voltage (kV) / Maximum Current (mA) / Date of acquisition of radiation apparatus / Purpose

10. 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.)

11. Particulars of Radiologists / Radiographers and designated Radiation Protection Officer (RPO), if any.

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

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

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

Amount……………………………………………………………………..

Date…………………………………………………………………………

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

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 Yes No

ii. Sketch of X-Ray room attached Yes No

iii. 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 021-9266281

** 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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