ML20237D228
| ML20237D228 | |
| Person / Time | |
|---|---|
| Issue date: | 08/24/1998 |
| From: | Kime T NRC OFFICE OF NUCLEAR MATERIAL SAFETY & SAFEGUARDS (NMSS) |
| To: | Kofender M AFFILIATION NOT ASSIGNED |
| References | |
| SSD, NUDOCS 9808250180 | |
| Download: ML20237D228 (2) | |
Text
.
August 24,1998 Marvin L. Kofender, M.D.
l 6900 Orchard Lake Road, Suite 207 West Bloomfield, MI 48322
Dear Dr. Kofender:
This letter verifies the receipt of the completed NRC Form 483 dated August 20,1998. This form is a condition of the general license under 10 CFR 31.11 authorizing in-vitro testing with byproduct material under general license.
The form has been assigned registration number 6963. When making changes to any of the information on the form, please reference the registration number and address the correspondence to Director, Office of Nuclear Material Safety and Safeguards, U.S. Nuclear Regulatory Commission, Washington, DC 20555.
If you have any questions or need further assistance, please contact me at (301) 415-8140.
Sincerely, 4
Traci Kime, Secretary Materials Safety Branch Division of Industrial and Medical Nuclear Safety Office of Nuclear Material Safety (f
and Safeguards DISTRIBUTION:
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SBaggett IMNS r/f NEO3 JMENT NAME: p:\\kofender.483 m a copy of this document. Indicate in the bos: "C" = Copy without attachment / enclosure "E" = Copy with attachment' enclosure "N" = No copy
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l DE TKime L m
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8/9/98 OFFICIAL RECORD COPY 9808250180 980824
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NRC FORM 483 U. S. NUCLEAR REaULATORY COMMISSION APPROVED BY OMB: NO 31500038 EXPIRES: 6-30-99 pe6; Esbmated buroen per response e compiy with this mandatory informanon collecbon request 7 mmutes The vahdated regatrabon netwes es avioence REGISTRATION CERTIFICATE --in vitro TESTING
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WITH BYPRODUCT MATERIAL UNDER Co.',," '"'m,","l ", 7e"'"**"' E"*"#sdE "e'd."***
c Paperwork Reduccon Prosect (316oo038). Othce or Management and GENERAL LICENSE s se w.snm
- n. oc 20 sos NRc me, n..ondum o, s-.nd e N
perun a not requwed e respond to, e conecnon or informanon union it
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duplays a cunency vend ous ~-~' number Section 31.11 of 10 CFR 31 establishes a general license authorizing physicians, clinical laboratories, hospitals, and veterinarians in the practice of veterinary medicine to possess certain small quantities of byproduct material,for in Wtro chnical or laboratory tests not invoMng the intemal or extemal administration of the uct material or the radiation therefrom to human being) or animals. Possession of byproduct material under 10 CFR 31.11 is not authortred until the
'nicallaboratory, hospital, or veterinarian in the practice of, veterinary medicine, has filed NRC Form 483 and received from the Commesson a c(y(
_orm 483 with a registration number.
- 1. NAME AND ADDRESS OF APPLICANT (See Instruc00n 3.B. below)
- 2. APPLICATION (Check one box only)
Whi8V L KofDJD E (2 P O.
l hereby apply for a registration number pursuant to 10 CFR 31, Section N3 CfMME D b /M ED. % M 31.11, f r use of byproduct materials for:
W TT bLD vTr (.cO, -rb
,lg g A. Myself, a duty licensed physician authorized to disperse drugs in the practice of medicine.
h B. The above-named clincallaboratory.
TREPHON NUMBER (Inchase has Code)
C. The above named hospital.
( 3 Lb I:f4 6 M D %L4 D Vetennanan in the practice of veterinary medicine 3.
INSTRUCTIONS:
A. Subrnit this form in duphcate to:
REGISTRATION NUMBER:
Medcal, Academic and Commercial Use
[ M (W A
/p* " fog'o, Safety Branch (T-8 F5)
Division of industrial and Medcal Nuclear Safety Offee of Nuclear Material Safety and Safeguards U.S. Nuclear Regulatory Commasson E
h L.'. TMCl23r h p13 tory Washington, DC 2055S 0001 e
.a> m ic 3 M n l
ia (At NRC, a registration number will be assigned and a validated copy
- C l
of NRC Form 483 will be retumed.)
Y B. In the box above, pnnt or type the name, address (including ZIP Code), and telephone number of the registrant physician, clincal (If this an in/$alregistrabon leave this space blank - number to be laboratory, hospital, or veterinarian in the practce of veterinary assigned by AIRC. // this is a change ofinformahon from a previously medicnne for whom or for which this regtstratnon form is filed.
registered general Econse, include your registradon number.)
- 6. If place of use a different from address lated above, give complete address:
- 8. CERTIFICATION i hereby certify that:
A.
All information in this registration certifcate is true and complete.
B.
The registrant has appropnate radiation measuring instruments to carry out the tests for which byproduct mater'al will be used under the general license of 10 CFR 31.11. The tests will be performed only by personnel competent in the use of the tristruments and in the handling of the byproduct rnatorials.
C.
I understand that Co.sm
-% regulations require that any change in the information fumished by a registrant on this registration certificate be reported to the Director of Nucieer Material Safety and Safe 2uards within 30 days from the effective date of such change.
0 1 have reed and understand the provisions of Section 31.11 of NRC regulations 10 CFR 31 (reprinted on the reverse side of this form); and I understand that the registrant is required to comply with those provmions as to all byproduct ma'arial which he receives, acquires, possesses, uses, or transfers under the general license for which the Registration Certsrcate is filed with the U.S. Nuclear Regulatory Commission.
PRINTED OR TYPED NAME AND TITLE OF APPLICANT SIGNAT E OF APPLICA T DATE
/
h$
YY f D Y ( h) Q [ l,L WD 4)/j WARNING:
FALSE. STATEMENTS IN THIS CERTIFICNh'h MAY BE SUBJdCT TO CML AND/OR CRIMINAL PENALTIES. NRC REGULATIONS REQUIRE THAT SUBMitISIONS TO THE N ' BE COMPLETE AND ACCURATE IN ALL MATERIAL RESPECTS.18 U.S.C. SECTION 1001 MAKES IT A CRIMI OFFENSE TO MAKE A WILLFULLY FALSE STATEMENT OR REPRESENTATION TO ANY DEPARTMENT OR AGENCY OF THE UNITED STATES AS TO l
ANY MATTER WITHIN ITS JURISDICTION.
NRcFoRMass tsas)