NOTE: This form must be used prior to ordering or receiving radioactive sealed sources, standards, gifts, collaborations, trades, or other third-party purchases that cannot be procured through Emory Express.

NO ACQUISITION IS TO OCCUR PRIOR TO RADIATION SAFETY APPROVAL

Instructions:

Complete form and fax or email to Radiation Safety for approval: (404) 727-5904 or chemwaste@emory.edu

Direct questions to 404-727-5922, or your assigned Health Physicist

All radioactive material must be received at Emory University, EHSO, 615 Michael Street, Suite G44, Atlanta, GA 30322, ATTN: Radiation Safety / {PI NAME}

Supplier Information	Receiver Information
Company/University	Principal Investigator
Address	Authorization #
City, State, Zip	Building
License #	Room# (for delivery)
RSO	Department
Phone	Contact (if not PI)
Fax	Phone
Email	Fax
Contact (if not RSO)	Email
Phone	License #	GA 153-1
Fax	Possession Limit
Email	Amount on Hand
Catalog Number	(inventory and waste)
Est. ship date	Signature of Authorized User
Est. delivery date

Product Information
Isotope	Physical/Chemical Form	Activity (uCi or mCi)	Volume (uL)	Qty (if > 1)

Special Instructions

Shipping Information (if known)
Carrier	Tracking No.

For Radiation Safety Office Use Only
Approved: Rejected:	By (Signature):	Date:
Comments/Reason Rejected:
EHSA Req. No.