Republic of the Philippines Department of Science and Technology




Republic of the Philippines

Department of Science and Technology

PHILIPPINE NUCLEAR RESEARCH INSTITUTE

Commonwealth Avenue, Diliman, Quezon City

 

APPLICATION FOR RADIOACTIVE Material LICENSE

(Brachytherapy) 
 

      INSTRUCTIONS: Accomplish this application and submit two (2) copies, including supplementary documents, personally to the Nuclear Regulations, Licensing and Safeguards Division (NRLSD), Philippine Nuclear Research Institute, Commonwealth Ave., Diliman, Quezon City. Use additional sheets, if necessary. 
       

  1. THIS IS AN APPLICATION FOR (check appropriate box) -

c a. New License  
c b. Amendment to License No.  
c c. Renewal of License No.  

 
 

  1. NAME AND MAILING ADDRESS OF APPLICANT

Institution/Hospital:  
   
Address:  
   
Telephone No(s).:  
Fax No.:  
E-mail Address:  

 
 

  1. LOCATION(S) OF USE

Name of Department:  
   
Room No(s).:  
Street:  
Telephone No(s).:  
Fax No.:  
E-mail Address:  

 
 

  1. N
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