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ORIGINAL REGISTRATION
State of IllinoisIllinois Emergency Management Agency - Division of Nuclear Safety
LASER REGISTRATIONILLINOIS EMERGENCY MANAGEMENT AGENCY -
DIVISION OF NUCLEAR SAFETY1035 OUTER PARK DRSPRINGFIELD, IL 62704
AMEND REGISTRATION
change of equipment
change of operator/address
LASERREGISTRATION NUMBER
IEMA will assign if new
The following information is provided in accordance with 32 Ill. Adm. Code 315 regarding laser registration.
ADMINISTRATOR / OWNER (NAME AND TITLE):
LASER SAFETY OFFICER:
FACILITY NAME:
CITY: STATE: ZIP: COUNTY:
FEIN/TAX FILING #:
E-MAIL: FAX:
This form properly compleed and filed with the Illinois Emergency Management Agency(IEMA), constitutes registration of the laser installations herein named in accordance withSection 20 of the Laser System Act of 1997 420 ILCS 56/20. IEMA is requesting disclosureof information that is necessary to accomplish the statutory purpose as outlined in 420ILCS 56/10. Disclosure of this information is required. Failure to comply with the provisionsof the Act is a Class B misdemeanor.
PRINT OR TYPE NAME
SIGNATURE DATEIOCI1025-10
LASER REF. NUMBER: Check here if new:
MANUFACTURER NAME:
MODEL NAME/NUMBER:
CONTROL SERIAL NUMBER:
ACQUISITION DATE:
LOCATION:
STATUS OF UNIT: Operable Inoperable Stored
Sold to supplier Junked Traded
Sold / Private:
Research Medical
Industrial Demonstration Entertainment
3b 4LASER CLASSIFICATION:
TELEPHONE:
Registration is required for Class 3b and Class 4 laser systems. All other laser systems areexempt. If the classification is unknown, refer to the label on the device. If you have anyquestions regarding laser classification or registration, please contact the Agency.
Is this a registered x-rayinstallation?
YES NO
STREET ADDRESS:
LASER USE:
LASER REF. NUMBER: Check here if new:
MANUFACTURER NAME:
MODEL NAME/NUMBER:
CONTROL SERIAL NUMBER:
ACQUISITION DATE:
LOCATION:
STATUS OF UNIT: Operable Inoperable Stored
Sold to supplier Junked Traded
Sold / Private:
Research Medical
Industrial Demonstration Entertainment
3b 4LASER CLASSIFICATION:
LASER USE:
LASER REGISTRATION FORM DEP-L
LASER REGISTRATION
COMMENTS:
LASER REF. NUMBER: Check here if new:
MANUFACTURER NAME:
MODEL NAME/NUMBER:
CONTROL SERIAL NUMBER:
ACQUISITION DATE:
LOCATION:
STATUS OF UNIT: Operable Inoperable Stored
Sold to supplier Junked Traded
Sold / Private:
Research Medical
Industrial Demonstration Entertainment
3b 4LASER CLASSIFICATION:
LASER USE:
LASER REF. NUMBER: Check here if new:
MANUFACTURER NAME:
MODEL NAME/NUMBER:
CONTROL SERIAL NUMBER:
ACQUISITION DATE:
LOCATION:
STATUS OF UNIT: Operable Inoperable Stored
Sold to supplier Junked Traded
Sold / Private:
Research Medical
Industrial Demonstration Entertainment
3b 4LASER CLASSIFICATION:
LASER USE:
LASER REF. NUMBER: Check here if new:
MANUFACTURER NAME:
MODEL NAME/NUMBER:
CONTROL SERIAL NUMBER:
ACQUISITION DATE:
LOCATION:
STATUS OF UNIT: Operable Inoperable Stored
Sold to supplier Junked Traded
Sold / Private:
Research Medical
Industrial Demonstration Entertainment
3b 4LASER CLASSIFICATION:
LASER USE:
LASER REF. NUMBER: Check here if new:
MANUFACTURER NAME:
MODEL NAME/NUMBER:
CONTROL SERIAL NUMBER:
ACQUISITION DATE:
LOCATION:
STATUS OF UNIT: Operable Inoperable Stored
Sold to supplier Junked Traded
Sold / Private:
Research Medical
Industrial Demonstration Entertainment
3b 4LASER CLASSIFICATION:
LASER USE:
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