ML20039G316
| ML20039G316 | |
| Person / Time | |
|---|---|
| Site: | 07002952 |
| Issue date: | 12/29/1981 |
| From: | Laura Smith AFFILIATION NOT ASSIGNED |
| To: | NRC OFFICE OF NUCLEAR MATERIAL SAFETY & SAFEGUARDS (NMSS) |
| References | |
| NUDOCS 8201180047 | |
| Download: ML20039G316 (2) | |
Text
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T y
w 1 n 195z PDK Wr4 b T). CA A m rt N '3 r E :
Tnic i nf orma t cn should oe ret aived by the U.S. h lear Regulatory g g _,'g r na i',s ion a t 1+ as t two weoks prior : C your tr.;.
t e-United States.
$1 Ih. e
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4[ R{CE[yh x x
'y Rad;oisotope_ L.ensing Branch Division of Fal ^ycle and g,3 T
% te rie l sa t ty
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Dgg g g un i te.' Stat es duc lear Regula tory Comi ss ionq'a u.s angqhte c
Wa J ington. D.C 20555 s'
n' be o t I ern'2n :
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The f o l lc ai ng i n)orma tion i s
- c.... tted in application for a license to possess >pec al nuclear material contained in an implanted nuclear pacemaF;-
powered card) i I.
(a)
Appl i _ ant 's Nahe
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Tvuntry City a
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Na'.i/dl rtg stry or License No. il any
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i (b) r:e nar o, addr"; and telephone nuniber ci the hospital, clinic or ap! ros iate auth arity in your country to be contacted in r
tase of an acci ;nt or malfunction of tne pacens ke r:
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Telep rot.__No.
il. Pam av er identifitation:
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Nuclear f uel r,__
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Milligram, to v'nsess the 6 !anteo nuclear powered-
.1; i h e rt-n y re-est i l i rw o 0
iriiac pa tei.sik e r as nu e ri t 'd above during my stay in the United hi.t es s,
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(Check One)
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United States.
I travel frequently (more than once a year) to the 6
m (b)
I will be in the Uni ted States f rom
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month day yea r y ?-
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o th ro ugh month day year tv. Trase! I t i nera ry.
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s V. Name(s) and address (es) of contact (- ) in the United States a.
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. - _ - _ - _ - _ - - __ m Vl. I will wear an 1@ntification brotelet to be supplied by me which E
is t i re resistent and of durable construction, and which is engraved
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[nylisn nith at least the following i n fo m1a t i o n :
in
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,iro to notify in your country in case of emergency, including f
telephone numbers to call in the event of an accident, or i
difficultly involving the pacemaker.
The words ' radioactive pacemaker i
P.n ena L r e manufacturer and model number.
1.
The iadiation symbol.
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Ine nane of the tcarer i
n.
Ident i f it a tinn (spelled out) of the radionuclide contained in the pacemaker.
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V'!
In addi'!un f any identity tard required ' n my c o u n t ry, I will arry on my person an identi ty card to be provided for my use by t
f the H Nuclear Regulatory Commission.
[
Sincerely,
. m ElF
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Name p ri n ted~ o r ty pe d 4 o e
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