Form NRC Form 664 NRC Form 664 General Licensee Registration

GL -

-

SECTION 1
PAGE 1 of 2

Date
NRC FORM 664
(12 -2006)
10 CFR 31.5

U.S. NUCLEAR REGULATORY COMMISSION

GENERAL LICENSEE REGISTRATION
APPROVED BY OMB: NO. 3150-0198

EXPIRES: MM/DD/YYYY

Estimated burden per response to comply with this mandatory collection request: 20 minutes. NRC will use this information to track general licensees and their devices to
ensure a higher level of device accountability. Send comments regarding burden estimate to the Records and FOIA/Privacy Services Branch (T-5 F53), U.S. Nuclear
Regulatory Commission, Washington, DC 20555-0001, or by internet e-mail to infocollects@nrc.gov, and to the Desk Officer, Office of Information and Regulatory Affairs,
NEOB-10202, (3150-0198), Office of Management and Budget, Washington, DC 20503. If a means used to impose an information collection does not display a currently valid
OMB control number, the NRC may not conduct or sponsor, and a person is not required to respond to, the information collection.

Complete all six sections of this registration form. If any of the preprinted information is incorrect, provide the
changes in the applicable boxes. USE CAPITAL LETTERS.
General License
Registration Number

SECTION 1 - GENERAL LICENSEE INFORMATION
-

GL -

Enter the company name and street address for the physical location of use for the device(s). For portable
devices, specify the primary storage location. Do not use P. O. Boxes.
Company Name:

Department:

Address Line 1:

Address Line 2:

City:

State:

-

Zip Code:

For NRC Use Only
(Do not write here)

Category:
Packet Receipt Date (MMDDYYYY)

Accession Number

>

>

GL -

-

SECTION 1
PAGE 2 of 2

Date

SECTION 1 - GENERAL LICENSEE INFORMATION (Continued)
Enter the name, telephone number, and title of the person who is the responsible individual for the device(s).
Last Name

First Name:

Middle Initial:

Telephone:

Extension:

-

-

Title:

Enter the mailing address where correspondence regarding your device(s) should be sent.
This address should be specific to the use or storage location of your device(s).
Department:

Address Line 1:

Address Line 2:

City:

State:

Zip Code:

>

-

>

GL -

-

SECTION 2
PAGE 1 of 1

Date

SECTION 2 - DEVICES SUBJECT TO REGISTRATION
Our records indicate that you have these devices. Please update the information as necessary.
NRC Device Key

Manufacturer Name:

Manufacturer License Number:

Device Model:

Device Serial Number:

Isotope:

Receipt Date: MM/DD/YYYY (if known)
Not in possession of device
(Also complete Section 4)

MM

DD

YYYY

NRC Device Key

Manufacturer Name:

Manufacturer License Number:

Device Model:

Device Serial Number:

Isotope:

Receipt Date: MM/DD/YYYY (if known)
Not in possession of device
(Also complete Section 4)

MM

>

DD

YYYY

>

GL -

-

SECTION 3
PAGE 1 of 1

Date

SECTION 3 - ADDITIONAL DEVICES SUBJECT TO REGISTRATION
Provide information about other devices you have that are subject to registration.
Manufacturer/Initial Transferor Name

Manufacturer/Initial Transferor License Number (if known)

Device Model Number

Device Serial Number

How acquired and date
(e.g., from a distributor/
manufacturer, other
licensee, other source)?

Manufacturer/Initial Transferor listed above
Date
Other General License
Received:
Other Source

MM

DD

YYYY

Isotope

Activity

Unit

Isotope

Activity

Unit

Isotope

Activity

Unit

Isotope

Activity

Unit

Isotope

Activity

Unit

Isotope

Activity

Unit

Isotope

Activity

Unit

Isotope

Activity

Unit

Isotope

Activity

Unit

Isotope

Activity

Unit

>

>

GL -

SECTION 4
PAGE 1 of 1

-

Date

SECTION 4 - NOT IN POSSESSION OF DEVICE

Provide information about devices listed in Section 2 or 6, but no longer in your possession.
Transfer Date

Part 1
NRC Device Key
(from Section 2 or 6)

MM

Location of the Device:

DD

YYYY

Whearabouts Unknown
(Complete Part 1 only)

Transferred to another general licensee:
(Complete Parts 2 and 3)

Never Possessed the Device
(Complete Part 1 only)

Disposed of/Transferred to a Specific Licensee
(Complete Part 2)

Returned to Manufacturer
(Complete Part 1 only)
Part 2
License Number of Recipient (if applicable)

Company Name:

Department:

Address Line 1:

Address Line 2:

City:

State:
Part 3

Zip Code:

-

Enter the name of the individual responsible for this device.

Last Name:

First Name:

Middle Initial:

Telephone Number:

Extension

-

-

Title

>

>

GL -

SECTION 5
PAGE 1 of 1

-

Date

SECTION 5 - CERTIFICATION

I hereby certify that:
A.

All information contained in this registration is true and complete to the best of my knowledge and belief.

B.

A physical inventory of the devices subject to registration has been completed, and the device information on this
form has been checked against the device labeling.

C.

I am aware of the requirements of the general license, provided in 10 CFR 31.5.
(Copies of applicable regulations may be viewed at the NRC web site at www.nrc.govreading-rm/doc-collections/cfr/

SIGNATURE - RESPONSIBLE INDIVIDUAL (Listed in Section 1)

DATE

WARNING: FALSE STATEMENTS MAY BE SUBJECT TO CIVIL AND/OR CRIMINAL PENALTIES. NRC
REGULATIONS REQUIRE THAT SUBMISSIONS TO THE NRC BE COMPLETE AND ACCURATE IN ALL
MATERIAL ASPECTS. 18 U.S.C. SECTION 1001 MAKES IT A CRIMINAL OFFENSE TO MAKE A
WILLFULLY WRONG STATEMENT OR REPRESENTATION TO ANY DEPARTMENT OR AGENCY OF THE
UNITED STATES AS TO ANY MATTER IN ITS JURISDICTION.

>

>

GL -

SECTION 6
PAGE 1 of 1

-

Date

SECTION 6 - DEVICES NOT SUBJECT TO REGISTRATION

NRC Device Key:

Manufacturer License No.:

Manufacturer Name:
Model Number:

Serial No.:

Transfer Date:

Isotope:

Activity:

Unit:

NRC Device Key:

Manufacturer License No.:

Manufacturer Name:
Model Number:

Serial No.:

Transfer Date:

Isotope:

Activity:

Unit:

NRC Device Key:

Manufacturer License No.:

Manufacturer Name:
Model Number:

Serial No.:

Transfer Date:

Isotope:

Activity:

Unit:

NRC Device Key:

Manufacturer License No.:

Manufacturer Name:
Model Number:

Serial No.:

Transfer Date:

Isotope:

Activity:

Unit:

NRC Device Key:

Manufacturer License No.:

Manufacturer Name:
Model Number:

Serial No.:

Transfer Date:

Isotope:

Activity:

Unit:

NRC Device Key:

Manufacturer License No.:

Manufacturer Name:
Model Number:

Serial No.:

Transfer Date:

Isotope:

Activity:

Unit:

>

>