Ref. L1
Radiation Protection and Nuclear Science Department
National Environment Agency
Environmental Building, 3rd Storey, Annex Block
40 Scotts Road, Singapore 228231
Email: Contact_NEA@nea.gov.sg
Website: http://www.nea.gov.sg
This form will take approximately 15 minutes to be completed.
Every section of the application form MUST be duly completed. “N.A.” should be used when appropriate.
Application form without the details of the irradiating apparatus, incomplete application form, or incorrect payment will result in the rejection of this application.
For payment by cheques, the accompanying cheque must be submitted together with the completed application form, failing which the form will not be processed.
1. Name of firm / organisation:
3. Address:
4a. Contact person:
2.
4b.
Company stamp:
Designation:
4c. NRIC / FIN No.:
6. Tel No.:
H.P. No:
5. Email address:
7. Fax No.:
8. Nature of business:
Company Unique Entity Number (UEN):
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Ref. L1
9. Particulars of the irradiating apparatus for which licence is sought:
Type/Purpose
(medical, dental, industrial)
Maker/Manufacturer
(a)
(b)
Model
(c)
10. Names of L5 licence holders or applicant who are applying for a L5 licence to use the irradiating apparatus for demonstration, maintenance, testing (if applicable):
11. Location where irradiating apparatus are to be operated for the purpose stated above (9).
12. Other remarks pertaining to this application (if any):
13. For medical irradiating apparatus, it is mandatory to attach documentations showing that the product(s) has been registered with HSA or granted waiver by HSA.
14. Mode of payment* (Check with your Finance Department before completing this section – Please Tick One Only):

Payment by GIRO (Your company must have a RPNSD Giro Account)

Payment by cheque – Bank/Cheque No: ___________________ (Please refer to Notes below.)

Payment by NETS or Credit Cards at NEA Customer Service Counter
*Note: Unless specially requested, the invoice and the receipt will be sent to the company address provided at
Sections 1 & 3 above. Cheques should be made payable to “National Environment Agency”. Payment by methods not specified above is liable to be rejected and will cause processing delay to your application.
15. I hereby apply for a licence to @ manufacture/possess for sale/deal in the irradiating apparatus specified above for a period as indicated and declare that all the particulars contained in this application are correct and true.
Months Fees (no GST) Please Tick One
3
6
9
12
24
$ 52.50/-
$105/-
$157.50/-
$210/-
$420/-
( )
( )
( )
( )
( )
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Ref. L1
@ Please note: If irradiating apparatus component parts (e.g. X-ray tube and control panels) are to be imported separately in different consignments and later assembled together as complete units, then this will constitute manufacturing. If no manufacturing is to be undertaken, please delete the word manufacture in this section.
The National Environment Agency (NEA) collects personal information to carry out its various functions and duties under the National Environment Agency Act (Cap 195) including the implementation of environmental and public health policies in Singapore and any other related purposes. I hereby consent to NEA’s use of the information provided by me in the course of any application I have made to the NEA, to facilitate the processing of such application for such purposes. I hereby further consent to NEA sharing the information in such application with other Government agencies, or non-government entities authorised to carry out specific government services, unless prohibited by legislation.
Name of Applicant Designation of Applicant
Signature of Applicant Date
Note:
1.
The attention of the applicant is drawn to Section 6(2) of the Radiation Protection Act 2007 which requires that notice of every sale of irradiating apparatus be given to the Director-General of Environmental Protection, National
Environment Agency. This application form is to be submitted to the Director, Radiation Protection and Nuclear
Science Department together with the name and address of the person to whom it was sold.
2.
The completed application form should be submitted together with catalogues, brochures, technical data and the prescribed fee to:
3.
You are encouraged to use GIRO for all payments. The GIRO application form and instruction can be found on the
NEA Website. Please do not hesitate to contact us if you need any assistance in applying for GIRO payments.
4.
Please call us at Tel. 6731 9309 if you need any assistance in filling up this form.
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