Radioactive Material Receiving Form
FROM:			TO:
ADDRESS:			ADDRESS:
CITY	STATE	ZIP CODE	CITY	STATE	ZIP CODE
LICENSE NO.		AGENCY	LICENSE NO.		AGENCY
CONTAINER	RADIATION	RADIATION	CONTENT: (LIST MAKE, MODEL, AND S/N)
PACKAGE TYPE	AT  CONTACT	AT 1 FT.
	MREM/hr.	MREM/hr.
		LABEL(S) APPLIED
		__W-1__Y-2__Y-3__INSTRUMENT & ARTICLES__LIMITED QUANTITIES
UN NUMBER	CURIE CONTENT	RADIONUCLIDE(S)	SEAL(S)	TRANSPORT INDEX (TI)
			___YES___NO
SURVEYED BY:		DATE	INSTRUMENT MAKE, MODEL, S/N		CALIBRATION DATE
REMARKS:
		ACKNOWLEDGEMENT OF RECEIPT
	NAME		DATE
	ORGANIZATION