Form NRC Form 749 NRC Form 749 Manual License Verification Report

OFFICIAL USE ONLY - SECURITY-RELATED INFORMATION
NRC FORM 749
(MM-YYYY)

U.S. NUCLEAR REGULATORY COMMISSION APPROVED BY OMB: NO. 3150-XXXX

MANUAL LICENSE
VERIFICATION REPORT

Submit by E-mail
EXPIRES: (MM/DD/YYYY)

Estimated burden per response to comply with this collection request: 8 minutes. This form is a
voluntary means of fulfilling the requirements in 10 CFR 37.71. The information provided will be used to
perform a license verification prior to transfer. Send comments regarding burden estimate to the FOIA,
Privacy, and Information Collections Branch (T-5 F53), U.S. Nuclear Regulatory Commission,
Washington, DC 20555-0001, or by internet e-mail to Infocollects.Resource@nrc.gov, and to the Desk
Officer, Office of Information and Regulatory Affairs, NEOB-10202, (3150-XXXX), 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.

Sections A-B to be completed by LVS Help Desk (if applicable). Sections C-D to be completed by the licensee: Complete sections C and D
below for NRC or Agreement State licensees needing to verify a license outside of the License Verification System. For issues with submitting this
form, please contact the LVS Help Desk: 1-877-671-6787 or E-mail: lvshelp.resource@nrc.gov.

Phone

A. CONTACTED VIA

E-mail

B. DATE (MM/DD/YYYY)

C. TRANSFERRING LICENSEE INFORMATION
C.1 Agency (issuing Agency for license)
C.2 Licensee Name
C.3 License Number
C.4 Contact Name and Title
C.5 Contact Telephone Number

C.7 Contact Fax Telephone Number

C.6 Contact E-mail Address
D. RECEIVING LICENSEE INFORMATION
D.1 Agency (issuing Agency for license)
D.2 Licensee Name
D.3 License Number

D.4 Amendment Number

D.5 Issue Date
D.6 Authorized Location
D.7 Material(s) of concern being requested D.8 Chemical/Physical Form

D.9 Quantity/Activity/Unit (being requested)

1.

1.

1.

2.

2.

2.

3.

3.

3.

4.

4.

4.

Sections E-F instructions (Agency representative to provide): Verify the information in Section D above and make sure that all information
provided is valid and the authorized location, materials and quantities being requested are authorized on the recipient's license. Record the
verification outcome below. Return the completed form via e-mail to the LVS Help Desk (lvshelp.resource@nrc.gov).

E. VERIFIER'S INFORMATION
E.1 Verifier's Name
E.2 Verifier's Telephone Number

E.3 Verifier's Fax Telephone Number

E.4 Verifier's E-mail Address
F. VERIFICATION OUTCOME
F.1 Verification Date
Requested materials, quantities, and
authorized location are authorized on the
license

F.2 Verification Outcome

Requested materials, quantities, and authorized
location are not authorized on the license

Other

F.3 If other, please explain:
NRC FORM 749 (MM-YYYY)

OFFICIAL USE ONLY - SECURITY-RELATED INFORMATION