Ref. L3
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
RADIATION PROTECTION ACT 2007
APPLICATION FOR A LICENCE TO HAVE IN POSSESSION
AN IONISING RADIATION IRRADIATING APPARATUS
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:
2.
Company stamp:
3.
Address*:
4a.
Contact person:
4b.
Designation:
4c.
NRIC / FIN No.:
5.
Email address:
6.
Tel No.:
7.
Fax No.:
H.P. No:
8.
Nature of business (dental, medical diagnosis or therapy, manufacturing, shipyard, refinery, etc.):
*Please include the Division and Department
Company Unique Entity Number (UEN):
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Ref. L3
9.
Name and address of company from whom irradiating apparatus is bought:
10.
Purpose of irradiating apparatus (e.g. medical diagnostic or therapeutic, dental, veterinary, industrial radiography,
maintenance, demonstration, research, materials inspection, product manufacturing, etc.):
11.
Particulars of irradiating apparatus for which licence is sought:
a)
Manufacturer:
b) Model:
c) Max. kV:
d) Max. mA:
e) Serial No.:
12.
Names of L5 licence holders or persons who are applying for L5 licence to use the irradiating apparatus:
1) Name:
__________________________
Signature:
__________________________
2) Name:
__________________________
Signature:
__________________________
13.
Location where the irradiating apparatus is to be kept and used:
14.
Give details of the shielding and safety arrangements made or to be made to protect the workers and other persons
against any radiation hazards. (Refer also to note 2 below):
15.
Other remarks pertaining to this application (if any):
16.
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.
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Ref. L3
17.
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.
18.
Months
Fees
Please Tick One
3
$ 40/-
(
)
6
$ 80/-
(
)
9
$120/-
(
)
12
$155/-
(
)
24
$310/-
(
)
I hereby apply for a licence to have in possession the irradiating apparatus specified above for a period as indicated and
declare that all the particulars contained in this application are correct and true.
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
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Ref. L3
Notes:
1.
A separate application is required for each irradiating apparatus.
2
In case of fixed installations, please supply architectural plan of room in which the irradiating apparatus is installed and
the surrounding area.
3.
The completed application form should be submitted together with catalogues, brochures, technical data and the
prescribed fee to:
Director
Radiation Protection and Nuclear Science Department
National Environment Agency
Environment Building
3rd Storey, Annex Block
40 Scotts Road, Singapore 228231
4.
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.
5.
Please call us at Tel. 6731 9309 if you need any assistance in filling up this form.
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