Note: The Shipping and Billing information supplied on the General application form will be used as the Personnel Monitoring Service addresses.
 

Please fill out the below information as complete as possible to subscribe to AEIL's Personnel Monitoring Service.
 

Exchange Period (check one): Semi-Monthly (___)
                                                            Monthly (___)
                                                       Bi-Monthly (___)
                                                          Quarterly (___)
 

We have the following external radiation exposure at our company (check and/or Specify under Other all that apply): X-ray (___) ; Cs-137 (___) ; Co-60 (___) ; Ir-192 (___) ; I-131 (___) ; I-125 (___) ; Tc-99 (___) ; Sr-90 (___) ; Other - Specify (___________________).
 

Please notify us by collect telephone or e-mail if any exposure exceeds the permissible dose of the above exchange period: Yes ______ No______.
 

We wish to subscribe to individual Statistical Summaries on a;
                                                                        Quarterly basis: Yes ______ No______.
                                                                            Annual basis: Yes ______ No______.
 
 

Badge Type
B-4 = Whole Body Film Badge for monitoring X-ray, Beta, Gamma
E-4 = Extremity Film Wrist Badge for monitoring X-ray, Beta, Gamma
F-4 = Extremity TLD Ring Badge for monitoring X-ray, Beta, Gamma
 
 
 

Please furnish us with the following information for each employee:
                                                                                                                              Gender     Badge
Last Name, Initials                            Social Security No.           Birth Date       (M/F)       Type

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Use additional pages as needed.