Radioactive Material Shipping Form
FROM:			TO:
ADDRESS:			ADDRESS:
CITY	STATE	ZIP CODE	CITY	STATE	ZIP CODE
LICENSE NO.		AGENCY	LICENSE NO.		AGENCY
CONTAINER	RADIATION	RADIATION	CONTENT: (IF SOURCE LIST MAKE, MODEL, AND S/N)
PACKAGE TYPE	AT  CONTACT	AT 1 FT.
	MREM/hr.	MREM/hr.
TRANSPORT GROUP (WASTE ONLY)		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:	"This is to certify that the above-named materials are properly classified, described,
	packaged, marked, and labeled, and are in proper condition for transportation, according to
	the applicable regulations of the Department of Transportation."
	R.S.O. Signature
	Date
		ACKNOWLEDGEMENT OF RECEIPT
	NAME		DATE
	ORGANIZATION