e-form

RPC - Importing Agent Notification Form

Please fill and submit form to: Radiation Protection Commission
For any queries, kindly contact the Radiation Protection Commission (email: info.rpc@gov.mt)

GENERAL

TYPE OF NOTIFICATION

PURPOSE OF NOTIFICATION

I. GENERAL INFORMATION

ORGANISATION DETAILS

I-1. Name of Employer

Organisation Address

Telephone Number

Organisation Address

Email Address

Note: The Radiation Protection Board will require notification prior to import of any equipment.

I-2. The Legally Responsible Person

Organisation Address

Full Name

Organisation Address

Position

Organisation Address

I.D. Number

Organisation Address

Telephone Number

Organisation Address

Email Address

I-3. Indicate briefly the nature and business of the radiation employer named in I-1 above

Organisation Address

I-4. Please complete relevant sheets II-1 and III-1 and/or III-2

I-5. Proposed date of commencement of the work activity

Date

II. SIGNATURE AND CERTIFICATION

II.1 Declaration

The radiological risks associated with the import of the equipment mentioned in this notification, have been analysed in the attached risk assessment and the nature and magnitude of the risks to staff and other persons arising from the use of the equipment have been analysed.

Title

I.D. Number

Date

I.D. Number

This form must be printed when filled, signed and submitted to the Commission via email (info.rpc@gov.mt) or by other means to address below.

Signature of the Legally Responsible Person

Notes:

1. This form will not be processed unless a written risk assessment is attached to this form.

2. Based on the processing of this form, the Radiation Protection Commissionmay require additional information to fully consider this application prior to issuing an authorisation.

3. In the event that all the above required information is not available at the time of application, the Radiation Protection Commissionmay issue an authorisation limiting the applicant to import, acquire, or store radiation sources or construct facilities. Complete information will be required from the applicant prior to authorising the use of the radiation sources.

4. The Radiation Protection Commission (RPC) will process your data in accordance with the principles of the Data Protection Act. RPC will not release information held about the applicant to third parties except where necessary for the fulfillment of this application. RPC may process the applicant's address, telephone, fax or email details to contact the applicant in connection with this application. Completion and submission of this application form signifies the applicant consent to the processing of this data. Please contact RPC if the applicant would like the RPC to inform the applicant about the personal data the RPC hold about the applicant if the applicant require such data to be corrected.

In the case of each sources, please state:

(1) Whether the source is sealed or unsealed

(2) (a) Manufacturer

(2) (b) Product or Catalogue Number

(3) The country of origin of the source

(4) The projected duration of use and the proposed fate of the source when it is no longer required

(5) The radionuclide and the activity of the source at time of application

(5) (a) Radionuclide

(5) (b) Activity (MBq)

(5) (c) Date of Manufacture

(6) The Physical form of the source (Solid, Liquid or Gas)

(7) Standard(s) to which the radioactive source complies with

(8) Standard(s) to which the source holder and/or container that emits radiation complies with

(9) Whether the source holder and/or container is portable or it will be used in a fixed position

(10) Model and, if available, Serial number of the source holder and/or container

(10) (a) Model Number

(10) (b) Serial Number

(11) Name & Address of forwarder in the exporting country