SCHEDULE 3 AMENDMENT APPLICATION FORM – PERSONNEL
This form, requesting approval for changes to Schedule 3 of an existing licence, must be completed and forwarded
to the EPA’s Office of Radiological Protection. Changes may include the inclusion/removal of an RPA, RPO, or other
personnel.
Licence No: _ __________________________________________________________________________________________________
Licensee Name: _ _______________________________________________________________________
Please state the name of the individual/corporate body you wish to have included on the licence:
Please indicate their position: RPA
RPO/Deputy RPO
Other:
If requesting approval for the appointment of an RPA or Corporate RPA from the EPAs’ Register:
Please attach evidence such as an email or letter from the RPA confirming the appointment.
If requesting approval for the appointment of an RPO:
Please outline their position within the organisation, and provide details of their qualifications and training in
radiation protection:
If requesting the removal of an individual/corporate body named on the schedule, please state the name of the
individual/corporate body you wish to have removed from the licence
__________________________________________________________________________________________
Office Use Only
Administration
Date P/W Rec: ________ Date P/W Checked: ___________ P/W Correct: Y/N Initials: _____
Inspectorate
P/W Approved: Y/N Initials: _____ Notes:
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I hereby apply for a Schedule 3 amendment to the above licence. I declare that to the best of my knowledge, the
particulars given above are true.
Signed: _______________________________________________________________________________________
Name (print or type): ____________________________________________________________________________
Position:
Date: ______________________________________
This Amendment Application Form must be signed by the Managing Director/Chief Executive, Hospital Manager (or
equivalent member of senior management), Radiation Protection Adviser (RPA) or Radiation Protection Officer (RPO)
nominated by the licensee submitting the Application. In the case of a licence issued in the name of an individual
person the form must be signed by that person.
On completion, this Amendment Application Form should be sent to:
Radiation Protection Regulation
Environmental Protection Agency
Office of Radiological Protection
3 Clonskeagh Square
Dublin 14
Telephone:
Fax:
Website:
(01) 2680100
(01) 2680199
www.epa.ie
Note: The form and any supporting documents may be scanned as a pdf and sent by email to radregulatory@epa.ie.
Version: August 2014
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