NRC Form 831 Report of Export

NRC FORM 831

(MM-YYYY)
10 CFR 110.50(c)(3)(i)

U.S. NUCLEAR REGULATORY COMMISSION APPROVED BY OMB: NO. 3150-0036

REPORT OF EXPORT

ADVANCED NOTIFICATION OF
SHIPMENT OF CATEGORY 1 AND/OR 2
RADIOACTIVE SOURCES
In accordance with 10 CFR Part 110.50(c)(3)(i)
of the U.S. NRC Regulations

Reference Number:
A

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 Information
Services Branch, (T-6 A10M), U.S. Nuclear Regulatory Commission, Washington, DC 20555-001, or by
e-mail to 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:
Name of the individual and licensee making the
notification: (address, city, state, zip code and
telephone number)

B

C

D

U. S. exporting facility:
(company name, address, city, state, zip
code and telephone number)

Foreign recipient name, address and end use
location(s) if different than recipient's address:

Radionuclide(s) and activity level in TBq, both
for single and aggregate shipments:
Total Activity Level (TBq):

E

Make, model and serial number, for any
category 1 and 2 sealed sources, if available:

F

End-use in the importing country, if known:

G

Shipment date: (MM/DD/YYYY)

H

This notification should be accompanied by a copy of the foreign recipient's authorization or confirmation
of that authorization from the government of the importing country, as required by 110.32(g).

Comments:

NRC Form 831 (MM-YYYY)