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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

APPLICATION FOR ORDERING RADIOACTIVE MATERIAL(Primary Isotopes,Radiochemicals,Radioppharmaceuticals,Labelled Compounds etc.)

3. Primary Isotopes,Radiochemicals,Radioppharmaceuticals,Labelled Compounds etc. (See note 5)a) Radioisotope : b) Code : c) Quantity/Activity: 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 & dusty5. Information for verifying AERB/BARC authorization quantity:

a) Is the applicant authorized by AERB/BARC to receive and use the above products: Yes / Nob) 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) Othersi) Oral ii) Injection iii) In vitro

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 beregistered as a purchase order for the material to which itrefers subject to the conditions of Sale listed overleaf.

10. I undertake to ensure any material supplied against thisapplication will not be used otherwise than described above.I undertake full responsibility when the material is used onhuman beings. I have read the explanatory notes andconditions of sale given overleaf.

Signature of personauthorised to sign thePurchase Order on behalf ofthe above institution

__________________Date :

Signature of applicant

Designation __________________Date :

Name, Designation &Seal of office

Name , Designation &Seal of Office

Purchase Order No & Date :For Office use only

Our ReferenceIGA/

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)

Name & Full address of Applicant: 2. To be Invoiced to:

NameDesignationDepartmentInstitutionAddress

City with pin

Phone Fax :E-Mail

NameDesignationDepartmentInstitutionAddress

City with pin

Phone Fax :E-Mail

A-1 Form

Customer Code : 1746

DR. T.C. KALAWAT DR. B. VENGAMMA

ADDITIONAL PROFESSOR DIRECTOR

NUCLEAR MEDICINE

SRI VENKATESWARA INSTITUTE OF SRI VENKATESWARA INSTITUTE OF

MEDICAL SCIENCES MEDICAL SCIENCES

TIRUPATI TIRUPATI

517507 517507

0877-2287777-2342 0877-2286803 0877-2287777-2222 0877-2286803

kalawat.svims@gmail.com svimstpt.ap.nic.in

153-Sm-EDTMP SAM-2 150 mCI

CHENNAI

7/31/2019 Brit a1 Form

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V N Purav Marg, Mumbai 400 094 ; Tel: 25573534, 25565535, 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 Boardand 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.

2. The consignees copy of the air consignment note is usually carried by the Airline along with the consignment itselfand users are advised to arrange collection of the consignment from the airline office on the basis of the despatch

advice/intimation sent by us.

3. 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.

4. 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.

5. Ever effort will be made to supply the products on the scheduled dates. In exceptional cases we may be constrainedto postpone / cancel the supply on account of unforeseen reactor shutdown or due to any unforeseen situation

beyond our control.

6. Order for sealed radiation sources in A/3 form, for Radiography sources in R/1 form, for labeled Biomolecules inB/1 form standing order for Radiopharmaceuticals in SA-4 form and for Neutron irradiation A/2 form.

7. Telephonic / Fax orders and orders by letter will not be entertained. Under very special circumstances advanceintimation may be given by telephone / fax and this should be followed by the application in A-1 form.

CONDITIONS OF SALE

1. The radioactive material supplied against this application must not be sold or transferred to any other user orotherwise disposed off except as advised by AERB/BARC.

2. Facilities for the safe storage, handling and use of the material prescribed by AERB/BARC from time to timemust be provided.

3. Material supplied against this application will be charged for according to prices currently in vogue. Packingand 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.

4. Lead containers used in packing of radioactive materials and classified as returnable are to be returned, freightpaid to CSSC, BRIT, V N Purav Marg, Mumbai 400 094.

5. Any complaint or discrepancy observed should be brought to our notice within two days of the receipt of theconsignment.

6. Cancellation of the order already placed should be made at least 7 days in advance of the scheduled date ofsupply.

7. The terms and conditions of supply stated above only will apply. We will not be bound by terms and conditionsstipulated by the applicant.