NRC Form 831A Report of Export and 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, Library, and
Information Collections Branch, (T-6 A10M), U.S. Nuclear Regulatory Commission, Washington, DC
20555-001, or by e-mail to Infocollects.Resource@nrc.gov, and the OMB Reviewer at: OMB Office of
Information and Regulatory Affairs, (3150-0036), Attn: Desk Officer for the Nuclear Regulatory Commission,
725 17th Street NW, Washington, DC 20503; e-mail: oira_submission@omb.eop.gov. The NRC may not
conduct or sponsor, and a person is not required to respond to, a collection of information unless the
document requesting or requiring the collection displays a currently valid OMB control number.

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)