A-1 Form

APPLICATION FOR ORDERING RADIOACTIVE MATERIAL

(Primary Isotopes,Radiochemicals,Radioppharmaceuticals,Labelled Compounds etc.)
Customer Code :

1746
2. To be Invoiced to: Name DR. B. VENGAMMA Designation DIRECTOR Department Institution SRI VENKATESWARA INSTITUTE OF MEDICAL SCIENCES Address
TIRUPATI 517507

Name & Full address of Applicant: Name DR. T.C. KALAWAT

Designation ADDITIONAL PROFESSOR Department NUCLEAR MEDICINE Institution SRI VENKATESWARA INSTITUTE OF Address MEDICAL SCIENCES
TIRUPATI

City with pin

City with pin Phone 0877-2287777-2222 Fax : E-Mail svimstpt.ap.nic.in

517507
0877-2286803

Phone 0877-2287777-2342 Fax : 0877-2286803 E-Mail kalawat.svims@gmail.com

3. Primary Isotopes,Radiochemicals,Radioppharmaceuticals,Labelled Compounds etc. (See note 5) a) Radioisotope : 153-Sm-EDTMP b) Code : SAM-2 c) Quantity/Activity: 150 mCI d) Specific Activity: e) Half-Life: f) Any further Information if not covered by code : 4. Type of operation envisaged using the radioisotope ( tick the appropriate box ) a) Simple wet b) Complex wet c) Simple dry d) Dry & dusty 5. Information for verifying AERB/BARC authorization quantity: a) Is the applicant authorized by AERB/BARC to receive and use the above products: Yes / No b) If yes, maximum activity authorized and its reference: c) Quantity of the radioisotope in stock on the required date: (item (c) relevant for radioisotopes with half-life more than 30 days) 6. Purpose of Use (tick the appropriate box) a) On humans b) Investigation on animals c) Research d) Others i) Oral ii) Injection iii) In vitro
CHENNAI 7. Delivery Instructions: Material is required on __________ Per. Collection/ by Air. Airport: ____________________ 8. Remarks if any:

9. If this application is accepted by BRIT it is to be registered as a purchase order for the material to which it refers subject to the conditions of Sale listed overleaf. Signature of person authorised to sign the Purchase Order on behalf of the above institution Name, Designation & Seal of office Purchase Order No & Date :

10. I undertake to ensure any material supplied against this application will not be used otherwise than described above. I undertake full responsibility when the material is used on human beings. I have read the explanatory notes and conditions of sale given overleaf. Signature of applicant Designation Name , Designation & Seal of Office __________________ Date :

__________________ Date :

For Office use only Our Reference IGA/

1. Payment received details : 2. Passed on to _______________________ for further action For Customer Support Services Cell (for Explanatory notes please see on the reverse side)
V N Purav Marg, Mumbai 400 094 ; Tel: 25573534, 2556 5535, 25574363 Mobile 9869454120/30 Fax: 91 22 2556 2161, 2558 1319 e-mail: sales@britatom.gov.in Website : http://www.britatom.gov.in

I.

EXPLANATORY NOTES

1.

The applicant is the person who is authorised to procure radioactive material by Atomic Energy Regulatory Board and will be in charge of the use, storage and responsible for making arrangement for the disposal of the radioactive material. Despatch advice indicating the date of despatch of consignment will be sent to the consignee and the consignee should arrange prompt collection of the consignment & confirm the same to BRIT. The consignees copy of the air consignment note is usually carried by the Airline along with the consignment itself and users are advised to arrange collection of the consignment from the airline office on the basis of the despatch advice/intimation sent by us. Application should be complete in all respects. The code and the name of the product should be invariably specified. Incomplete and incorrect applications are liable to be returned to the applicant for corrections. Indicate the specific activity in millicuries per gram of activated element, or specify carrier-free as applicable. In case of carbon-14 and tritium labeled compounds, indicate the specific activity in millicurie per millimole. Ever effort will be made to supply the products on the scheduled dates. In exceptional cases we may be constrained to postpone / cancel the supply on account of unforeseen reactor shutdown or due to any unforeseen situation beyond our control. Order for sealed radiation sources in A/3 form, for Radiography sources in R/1 form, for labeled Biomolecules in B/1 form standing order for Radiopharmaceuticals in SA-4 form and for Neutron irradiation A/2 form. Telephonic / Fax orders and orders by letter will not be entertained. Under very special circumstances advance intimation may be given by telephone / fax and this should be followed by the application in A-1 form.

2.

3.

4.

5.

6.

7.

CONDITIONS OF SALE

1.

The radioactive material supplied against this application must not be sold or transferred to any other user or otherwise disposed off except as advised by AERB/BARC. Facilities for the safe storage, handling and use of the material prescribed by AERB/BARC from time to time must be provided. Material supplied against this application will be charged for according to prices currently in vogue. Packing and freight charges will be invoiced in addition. On receipt of the corresponding invoice by the invoice (column 2), payment if any, is to be made by crossed DD drawn on State Bank of India or any Mumbai branch of a scheduled bank in favour of Accounts Officer, BRIT and sent to Accounts Officer, BRIT, V N Purav Marg, Mumbai 400 094. Please note that cheques are not acceptable and all users should make payment by DD. Lead containers used in packing of radioactive materials and classified as returnable are to be returned, freight paid to CSSC, BRIT, V N Purav Marg, Mumbai 400 094. Any complaint or discrepancy observed should be brought to our notice within two days of the receipt of the consignment. Cancellation of the order already placed should be made at least 7 days in advance of the scheduled date of supply. The terms and conditions of supply stated above only will apply. We will not be bound by terms and conditions stipulated by the applicant.

2.

3.

4.

5.

6.

7.

V N Purav Marg, Mumbai 400 094 ; Tel: 25573534, 25565535, 25574363 Mobile 9869454120/30 Fax: 91 22 2556 2161, 2558 1319 Website : http://www.britatom.gov.in e-mail: sales@britatom.gov.in