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Radiation Safety Network
 Request for Listing
Radioactive Material or Device
Send Formor FAX FORM TO: (210-256-9599)
               For Sale [  ]         or Wanted [  ]           HELP
 Contact:
Device:  Name: 
Isotope:  Address1:
Quantity:  Address2:
Date Quantity Determined:  City, State, Zip: 
Model No:  Area Code and Phone: 
Principle Design Use:  Area Code and Fax: 
Area Code and Cell:
Condition of Device: 
Asking/Offering Price:  email:
Additional Info:
Fee:  [  ] 30 days          $75       (check one)
          [  ] 60 days         $100
          [  ] 90 days         $125
                ($25 for each additional 30 days)
          or
         [  ]  WANTED    $25 for each 60 days		 MAIL Form/Payment To:John R Haygood
                                   1779 Wells Branch Pkwy
                                   #110B - PMB 282
                                   Austin, TX  78727

Note:  Form must be printed and mailed.
Notice:  By submitting this request form you acknowledge your understanding that non-exempt radioactive materials cannot be transferred to another party unless the recipient holds a valid radioactive material license, issued by the US NRC or an Agreement State, which authorizes the Isotope, quantity, form and model number being transferred.  The transferor must make the verification prior to the transfer (see your applicable rules/regulations).

NOTE:  Listing will not be posted until payment is received.

 Notice: By submitting this form you indicate that you understand, acknowledge, and accept that the various laws, rules, regulations, and requirements of regulatory agencies are continually changing.  You further understand, acknowledge, and accept  that John R. Haygood, Southwestern Bell Internet Services(TM), Netscape Communications Corporation, MicroSoft, and other involved internet companies and entities are not responsible for errors, omissions, changes, accidents, and other problems associated with the transfer of information via electronic, mail, or delivery systems, nor for any transfer of property.  You accept responsibility for complying with the regulatory agency(s) requirements and do not hold responsible any of the aforementioned parties.
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INSTRUCTIONS and EXAMPLES:

Device:  Enter the basic type of device - M/D Gauge, Industrial Radioagraphy Camera, etc. -- or enter the form, ie, sealed source,
               plated source, etc.

Isotope:  Use the form Cesium-137 or Cs-137.

Quantity:  Enter quantity in units/subunits of Curies 
               mCi = millicurie
               uCi = microcurie
      Note:  you should also enter the equivalent SI units.

Date Quantity Determined:  Enter the effective date that the source quantity was determined -- or the calculated "current" quantity.

Model No:  Enter the manufacturer's model number designation for the unit, or, if a general sealed source, enter the sealed source
                    model number.

Principle Design Use:  If applicable, enter the type of use that the device/source originally was designed for.  Indicate whether medical,
                                          industrial, educational, etc.

Condition of Device:  Use your own judgement.

Asking/Offering Price: Optional.

Additional Info:  Add any information that might be useful to a potential user.

Note:  This form is not editable.  You must print it, add the information, and fax or mail it to the indicated fax number or
           mailing address, respectively.
 
 

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