Request for Amendment to Nuclide Authorization (Form 99s)

Authorized User*
Phone*
Address*
Street Address
NUCLIDE Additions or Changes Indicate desired New nuclides or changes in Order or Possession limits. If this is because of a change in protocols, include a summary of protocol changes.
Nuclide 1: Current Limits (mCi)
Nuclide
Order
Possession
Nuclide 1: Requested Limits (mCi)
Order
Possession
Nuclide 2: Current Limits (mCi)
Nuclide
Order
Possession
Nuclide 2: Requested Limits (mCi)
Order
Possession
Nuclide 3: Current Limits (mCi)
Nuclide
Order
Possession
Nuclide 3: Requested Limits (mCi)
Order
Possession
This change may require you to purchase a Survey Meter, if so, indicate.
Survey Meter Make:
Probe Type:
ROOM Additions or Deletions
Add
Delete
Building
Room
Add
Delete
Building
Room
Add
Delete
Building
Room
Please type your name into the signature field below. In doing so you certify this form, agree to comply with its conditions, and accept responsibility for radiation safety in your lab
Authorized User Signature:*
For a copy of this form, please print it from your browser now.
Name
This field is for validation purposes and should be left unchanged.