RSO CERTIFICATION APPLICATION FORM

A.3 Licensee Information

SECTION A – APPLICANT

Canadian Head Office Address:

City:

Street:

Licensee Name:

Province: Postal Code:

City:

Street:

Province: Postal Code:

Mailing Address (if different from above):

New Certification Certification amendment for additional use types

A.1 Type of Request

SECTION B – RADIATION SAFETY OFFICER CANDIDATE INFORMATION AND QUALIFICATIONSB.1 Candidate Information

A.2 Language of CertificateEnglish French Both

continued on next page

Name:

Candidates CV appended as:

I certify that all information submitted in this application and on supplementary pages is true and correct.

Signature of Candidate:

Title: Telephone:

Email: Facsimile:

Licensee Business Number:

CNSC License Number(s):

Canadian Nuclear Safety Commission Page 2 of 3

C.1 Licensed Activities

SECTION C – LICENSED ACTIVITIES AND LOCATIONS

D.1 Applicant Authority

SECTION D – LEGAL SIGNING AUTHORITY

Operate Medical Linear Accelerator

Additional sites appended as:

Operate Brachytherapy remote afterloader - low dose rate (LDR)

Operate Research or Industrial Particle Accelerator

Operate Isotope Production Accelerator

Operate Geophysical Logging Accelerator

Operate Portable Accelerator

Operate Mobile Accelerator

Operate Veterinary Teletherapy machine

Servicing of Class II Prescribed Equipment (By Operator)

Operate Neutron Generator

Servicing of Class II Prescribed Equipment (By Independent Provider)

Operate Stereotactic Teletherapy machine

Development and testing of Class II Prescribed Equipment

Other (Describe):Operate Pool-type Irradiator

Operate Irradiator

Operate Radioactive Source Teletherapy machine

Operate Brachytherapy remote afterloader - high dose rate (HDR) or pulsed does rate (PDR)

C.2 LocationsSite 1:

City:

Street:

Province: Postal code:

Site 2:

City:

Street:

Province: Postal code:

Signature: Date:YYYY MM

/DD

/

Name:

The personal information on this form is required for the purpose of completing an application to certify an individual as a radiation safety officer in accordance with section 15 of the Class II Nuclear Facilities and Prescribed Equipment Regulations. The collection of the information is mandatory and is protected by the provisions of the Privacy Act. If the noted information is not provided, CNSC will not be able to certify an individual as a radiation safety officer. The information collected will only be used and disclosed to conduct an assessment of a candidate's ability to perform the duties of radiation safety officer in order to become certified. The personal information collected for the Licensing and Certification Program is described in PIB CNSC PPU 025 within the CNSC Info Source Chapter.

I certify that all statements and representations made in this application and on supplementary pages are true and correct to the best of my knowledge. The applicant authority confirms that the candidate is capable of performing the role of RSO as defined by the licensee.

Title:

Canadian Nuclear Safety Commission Page 3 of 3

Mail the completed application form, together with all relevant documentation to:

The application form, together with all relevant documentation may also be submitted electronically.

Canadian Nuclear Safety CommissionDirectorate of Nuclear Substance RegulationP.O. Box 1046, Station B280 Slater StreetOttawa ON, K1P 5S9

Fax: 613-995-5086

Email: forms-formulaires@cnsc-ccsn.gc.ca