AERB/RSD/TR/Adv/PORT CLEARANCE/2002/REV.

1 GOVERNMENT OF INDIA ATOMIC ENERGY REGULATORY BOARD Niyamak Bhavan, Mumbai-400 094 APPLICATION FORM FOR OBTAINING PORT CLEAANCE

1.

Details of the consignment (a) Name of Radioactive Material : (b) Activity (c) Type of Package (As A, B(U), B(M), C) : :

(d) Category of Package : (As I-WHITE, II-YELLOW etc.) (e) Form of Radioactive Material : 2. 3. 4. Name of the Ship Voyage No. : : Special Form/Other than Special Form

Date of Arrival of ship in port : (If exact date is not known, the expected or likely date) Name and Address of the Consignor:

5.

6.

Name and Address of the Consignee:

7.

Mode of Transport from Port to Destination: (by road/rail etc.) Whether NO Objection Certificate for the procurement of the above: source is obtained from AERB. Any other information(which in your opinion can be helpful to PORT AUTHORITIES in locating and identifying the consignment). : Yes/No

8.

9.

Signaure :

Name: Address: