Department of Human Services, Radiation Protection Services 800 NE Oregon Street, #640 Portland, OR 2025

1. Click ‘Get Form’ to open the application in the editor.
2. Begin by selecting the type of application: New License, Amendment to License No., or Renewal of License No. Fill in your choice in the designated field.
3. Provide your Name and Mailing Address in the specified fields to ensure proper identification.
4. Enter the address(es) where licensed radioactive material will be used or stored. This is crucial for compliance.
5. Identify a contact person for this application by filling out their Name, Title, Phone, Fax, and E-mail.
6. For items 5 through 11, prepare additional information on 8.5" x 11" paper as required. Include details such as Element and mass number, Chemical form, Maximum amount possessed at any one time.
7. Outline the purpose for which licensed material will be used and provide details about training for individuals working with materials.
8. Complete sections on Facilities and Equipment, Radiation Safety Program, Waste Management, and responsible individuals' training.
9. Finally, ensure that the Certification section is filled out accurately by printing your name & title, signing it, and dating it before submission.

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