Form PA-NRS "Application for Notice of Registration" - Alabama

What Is Form PA-NRS?

This is a legal form that was released by the Alabama Department of Public Health - a government authority operating within Alabama. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • The latest edition provided by the Alabama Department of Public Health;
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  • Fill out the form in our online filing application.

Download a printable version of Form PA-NRS by clicking the link below or browse more documents and templates provided by the Alabama Department of Public Health.

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PA-NRS
ALABAMA DEPARTMENT OF PUBLIC HEALTH
APPLICATION FOR NOTICE OF REGISTRATION
(Calibration, Surveys, Installations, and Maintenance of Particle Accelerators)
Under the provision of Section 6, Act Number 582 of the 1963 regular session of the State Legislature, the State Board of Health is
designated as the State Radiation Control Agency, and is authorized to require registration and inspection of persons dealing with
ionizing radiation.
1. Name, mailing address of applicant (person, corporation, etc.)
Contact Name:
Telephone No: Area Code (
)
2. Services (Name each person below that will perform “services”, and check appropriate “services” which that person is qualified
to perform. Use supplemental sheets if necessary.
Radiation
Calibration
Name
Installation
Maintenance
Surveys
3. Training and experience. The training and experience of each person named in Item 2. above will be evaluated on an
individual
basis for the “services” checked. Calibration services will only be granted to “qualified experts” as defined in Rule 420-3-26-
.01(2)(a)77. The training and experience of each person must be submitted on individual supplemental forms (PA-NRS-1).
(Continued on Reverse Side)
PA-NRS
ALABAMA DEPARTMENT OF PUBLIC HEALTH
APPLICATION FOR NOTICE OF REGISTRATION
(Calibration, Surveys, Installations, and Maintenance of Particle Accelerators)
Under the provision of Section 6, Act Number 582 of the 1963 regular session of the State Legislature, the State Board of Health is
designated as the State Radiation Control Agency, and is authorized to require registration and inspection of persons dealing with
ionizing radiation.
1. Name, mailing address of applicant (person, corporation, etc.)
Contact Name:
Telephone No: Area Code (
)
2. Services (Name each person below that will perform “services”, and check appropriate “services” which that person is qualified
to perform. Use supplemental sheets if necessary.
Radiation
Calibration
Name
Installation
Maintenance
Surveys
3. Training and experience. The training and experience of each person named in Item 2. above will be evaluated on an
individual
basis for the “services” checked. Calibration services will only be granted to “qualified experts” as defined in Rule 420-3-26-
.01(2)(a)77. The training and experience of each person must be submitted on individual supplemental forms (PA-NRS-1).
(Continued on Reverse Side)
4. Radiation Detection Instruments
Type of Instruments
Number
Radiation
Sensitivity
Emergency
Use (Monitoring,
(Include make and
Available
Detected
Range (mr/hr)
Response
Surveying, Measuring)
model number of each)
5. Method, Frequency and Standards Used in Calibrating Instruments Listed Above
6. Film Badges and Dosimeters (For film badges, indicate the name of the supplier, and frequency of exchange. For dosimeters
indicate the name of the manufacturer, model number, range and method of calibration).
7. Certification: The applicant and any official executing this certificate on behalf of the applicant named in Item 1, certifies
that this application is prepared in conformity with Chapter 420-3-26, and that all information contained herein,
including any supplements attached hereto, is true and correct to the best of our knowledge and belief.
________________________________
______________________________________
______________________
Signature of Certifying Official
Printed Name and Title of Certifying Official
Date
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