SHIPMENT OF SEALED SOURCES BETWEEN THE MEMBER STATES OF THE EUROPEAN
Standard document to be used pursuant to Council Regulation (EEC) No 1493/93
- The consignee of sealed sources must complete boxes 1 to 5 and send this form to the relevant competent authority in his country.
- The competent authority of the consignee Member State must fill in box 6 and return this form to the consignee.
- The consignee must then send this form to the holder in the forwarding country prior to the shipment of the sealed sources.
- All sections of this form must be completed and boxes ticked, where appropriate.
1. THIS DECLARATION CONCERNS:
ONE SHIPMENT (This form is valid until the shipment is completed unless otherwise stated in box 6)
Expected date of shipment (if available):
SEVERAL SHIPMENTS (This form is valid for three years unless otherwise stated in box 6)
2. DESTINATION OF THE SOURCE(S)
Name of consignee:
Person to contact:
________________________________________________________________________________________________3. HOLDER OF THE SOURCE(S) IN THE FORWARDING COUNTRY
Name of holder:
Person to contact:
Tel.: Fax: ___________________________________________________________________________________________________________
4. DESCRIPTION OF THE SOURCE(S) INVOLVED IN THE SHIPMENT(S)
Maximum activity of individual source (MBq):
Number of sources:
If this (these) sealed source(s) is (are) mounted in (a) machinery/device/equipment, short description of the machinery/device/equipment:
(e) Indicate (if available and requested by the competent authorities):
national or international technical standard with which the sealed source(s) complies(y) and certificate
date of expiry of certification:
name of the manufacturer and catalogue reference:
5. DECLARATION OF THE AUTHORIZED OR RESPONSIBLE PERSON
I, the consignee, hereby certify that the information provided in this form is correct.
I, the consignee, hereby certify that I am licensed, authorized or otherwise permitted to receive the source(s) described in this form.
License, authorization or other permission number (if applicable) and validity date there of:
Name: Signature: Date:
6. CONFIRMATION BY THE COMPETENT AUTHORITY OF THE CONSIGNEE COUNTRY THAT IT HAS TAKEN NOTE OF THIS DECLARATION.
Name of the authority:
This declaration is valid until (if applicable):
Please see box 1, page 1, for guidance on the length of time this form is valid.