University of California, Santa Barbara Environmental Health and Safety
PERMIT HOLDER’S STATEMENT OF
TRAINING AND EXPERIENCE USING IONIZING RADIATION
Full Name: Position Title:
Department: Phone #:
Education/training
Education specifically applicable to use of radioactive material or radiation-producing machines.
(include degree(s) and courses, if any, in radiation safety):
EXPERIENCE
Experience with use of radioactive material or radiation-producing machines.
A. List relevant experience beginning with most recent dates:
1). From: to: Employer:
Title and duties:
2). From: to: Employer:
Title and duties:
3). From: to: Employer:
Title and duties:
B. For radioactive materials previously used, list typical radioisotopes and amount (millicuries):
Sealed (encapsulated) sources:
Unsealed sources:
C. For radiation-producing machine(s) previously used, describe machine(s):
I hereby certify that all information contained in this Statement of Training and Experience is
true and correct..
Applicant’s Signature Date
10/15/2004 (APPENDIX B-15)
ERASMUS INSTITUTIONAL KEY DATA NORWEGIAN UNIVERSITY OF
FO GUANG UNIVERSITY CHINESE LANGUAGE INSTRUCTION CENTER
IGNOU THE PEOPLE’S UNIVERSITY INDIRA GANDHI NATIONAL OPEN
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