Name of the designated officer*:(Head/RSO/site in charge/other)

(*Responsible for maintaining PersonalMonitoring device/dose data)

Phone/Mobile Fax E-mail Phone/Mobile Fax E-mail 3.Type of radiation for which monitoring is required GammaX-rayNeutronsBetaOther Charge ParticlesContract New RenwalContract Period per years Starting Date
Champ de répéteur

6. Radiation Liense No (MoE for handling of radiation sources:) 7.Type of application of radiation source/s IndustrialResearchMedicalNuclear Fuel Cycle

I HAVE READ THE PM BADGE USER’S INSTRUCTION MANUAL AND THE ATTACHED TERMS AND CONDITIONS AND I UNDERTAKE TO,
1. Comply with all instructions stated in the manual and any other future instructions given by theCompetent Authority MME.
2. Comply with the regulatory requirements for handling of radiation sources (i.e. radioactive material andradiation generating machines) stipulated by Competent authority MME.
3. Investigate the cases of over-exposures or contamination of TLD/OSLD cards and send the reports promptlywhenever called for to MME.
4. Return the TLD/OSLD /neutron badges promptly after the end of the stipulated monitoring period.
5. Ensure that TLD/OSLD /neutron badges are stored in normal radiation background.
6. Ensure that Personal monitoring badges shall be used exclusively by the worker who has been issued thebadge. It shall not be issued to any other person.
7. Intimate any change in the data regarding radiation sources to the Service Provider.

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