NRC Form 831A Report of Export Continuation Sheet

NRC FORM 831A
(MM-YYYY)
10 CFR 110.50(c)(3)(i)

U.S. NUCLEAR REGULATORY COMMISSION

REPORT OF EXPORT
CONTINUATION SHEET
ADVANCED NOTIFICATION OF
SHIPMENT OF CATEGORY 1 AND/OR 2
RADIOACTIVE SOURCES

In accordance with 10 CFR Part 110.50(c)(3)(ii)
of the U.S. NRC Regulations

Reference Number:

APPROVED BY OMB: NO. 3150-0036

EXPIRES: (MM/DD/YYYY)

Estimated burden per response to comply with this mandatory collection request: 30 minutes.
This form allows the NRC to request additional information from licensees to determine whether a
license should be revoked, suspended, or modified. Send comments regarding burden estimate
to the FOIA, Privacy, and Information Collections Branch (T-5 F53), U.S. Nuclear Regulatory
Infocollects.Resource@nrc.gov, and to the Desk Officer, Office of Information and Regulatory
Affairs, NEOB-10202, 3150-0036, Office of Management and Budget, Washington, DC 20503. If a
means used to impose an information collection does not display a currently valid OMB control
number, the NRC may not conduct or sponsor, and a person is not required to respond to, the
information collection.

SEND COMPLETED FORM TO:

U.S. Nuclear Regulatory Commission
ATTN: Headquarters Operation Center
Email: hoo.hoc@nrc.gov (Preferred Reporting Method)
Fax: (301) 816-5151 (Alternative Reporting Method)

Part 110 License Number:
Expiration Date of Part 110 License Number:
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NRC Form 831A (MM-YYYY)

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