Fillable Printable Application for NRC Export or Import License, Amendment, Renewal, or Consent Request(s)

Application for NRC Export or Import License, Amendment, Renewal, or Consent Request(s)

NRC FORM 7

(11-2012)

10 CFR 110

U. S. NUCLEAR REGULATORY COMMISSION

APPROVED BY OMB: NO. 3150-0027

EXPIRES: (11/30/2015)

Page 1 of

PART A. FOR NRC USE ONLYOR

PUBLICNON-PUBLIC

DATE RECEIVED

LICENSE NUMBERDOCKET NUMBER

ADAMS ACCESSION NUMBER

PART B. TO BE COMPLETED FOR ALL LICENSES, AMENDMENTS, RENEWALS, OR CONSENT REQUESTS

(If more space is needed to complete any of the items, use Pages 3-4 first, and then attach additional sheets, if necessary.)

1. NAME AND ADDRESS OF APPLICANT/LICENSEE

1a. NAME OF APPLICANT'S CONTACT

1b. APPLICANT'S REFERENCE NUMBER

1c. PHONE NUMBER1d. FAX NUMBER

1e. E-MAIL ADDRESS

2. TYPE OF ACTION REQUESTED (Check One)

3. CONTRACT NUMBER(S)4. FIRST SHIPMENT DATE5. LAST SHIPMENT DATE6. PROPOSED EXPIRATION DATE

PART C. TO BE COMPLETED FOR EXPORT LICENSES, AMENDMENTS, OR RENEWALS

(If more space is needed to complete any of the items, use Pages 3-4 first, and then attach additional sheets, if necessary.)

7. NAME(S) / ADDRESS(ES) OF SUPPLIERS

AND/OR OTHER PARTIES TO THE EXPORT

7a. FUNCTION(S) PERFORMED/SERVICE(S) PROVIDED

8. NAME(S) / ADDRESS(ES) OF INTERMEDIATE

FOREIGN CONSIGNEE(S)

8a. INTERMEDIATE USE(S)

9. NAME(S) / ADDRESS(ES) OF ULTIMATE

FOREIGN CONSIGNEE(S)

9a. ULTIMATE END USE(S)

10. DESCRIPTION OF RADIOACTIVE MATERIALS, SEALED SOURCES,

NUCLEAR FACILITIES, EQUIPMENT, OR COMPONENTS; FOR

NUCLEAR EQUIPMENT INCLUDE TOTAL DOLLAR VALUE OF

EQUIPMENT FOR EXPORT

10a. MAX TOTAL VOLUME /

ELEMENT WGT (KG), OR

TOTAL ACTIVITY (TBq)

10b. MAX ENRICHMENT

OR WGT %

10c. MAX ISOTOPE

WGT (KG)

11. FOREIGN OBLIGATIONS (BY COUNTRY AND BY PERCENTAGE OF MAXIMUM TOTAL VOLUME)

NRC FORM 7 (11-2012)

APPLICATION FOR NRC EXPORT OR IMPORT

LICENSE, AMENDMENT, RENEWAL,

OR CONSENT REQUEST(S)

(See Instructions on Pages 4 and 5)

Estimated burden per response to comply with this mandatory collection request: 2.4 hours. This

submittal is reviewed to ensure that the applicable statutory, regulatory, and policy

considerations are satisfied. Send comments regarding burden estimate to the Information

Services Branch (T-5 F53), U.S. Nuclear Regulatory Commission, Washington, DC 20555-0001,

or by internet e-mail to [email protected], and to the Desk Officer, Office of

Information and Regulatory Affairs, NEOB-10202, (3150-0027), 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.

EXPORT

(Parts B, C, E)

IMPORT

(Parts B, D, E)

AMENDMENT/RENEWAL

Current License Number:

CONSENT REQUEST

(Parts B, C)

Current License Number:

U. S. NUCLEAR REGULATORY COMMISSIONNRC FORM 7

(11-2012)

10 CFR 110

APPLICATION FOR NRC EXPORT OR IMPORT

LICENSE, AMENDMENT, RENEWAL, OR CONSENT REQUEST(S) (Continued)

Page 2 of

LICENSE NUMBER

DOCKET NUMBER

PUBLICNON-PUBLIC

PART D. TO BE COMPLETED FOR IMPORT LICENSES, AMENDMENTS, OR RENEWALS

(If more space is needed to complete any of the items, use Pages 3-4 first, and then attach additional sheets, if necessary.)

12. NAME(S) / ADDRESS(ES) OF FOREIGN

SUPPLIERS AND/OR OTHER PARTIES

TO IMPORT

12a. NRC EXPORT LICENSE NUMBER(S)

(if applicable)

13. NAME(S) / ADDRESS(ES) OF INTERMEDIATE

CONSIGNEE(S)

13a. LICENSE NUMBER(S) / EXPIRATION DATE(S)

13b. INTERMEDIATE USE(S)

14. NAME(S) / ADDRESS(ES) OF ULTIMATE U. S.

CONSIGNEE(S)

14a. LICENSE NUMBER(S) / EXPIRATION DATE(S)

14b. ULTIMATE END USE(S)

15. DESCRIPTION OF RADIOACTIVE MATERIALS, SEALED SOURCES,

NUCLEAR FACILITIES

15a. MAX TOTAL VOLUME /

ELEMENT WGT (KG), OR

TOTAL ACTIVITY (TBq)

15b. MAX ENRICHMENT

OR WGT %

15c. MAX ISOTOPE

WGT (KG)

16. FOREIGN OBLIGATIONS (BY COUNTRY AND BY PERCENTAGE OF MAXIMUM TOTAL VOLUME)

17. ADDITIONAL INFORMATION

PROVIDED ON PAGES 3, 4,

AND/OR ON SEPARATE SHEETS?

17a. COPIES OF RECIPIENTS'

AUTHORIZATIONS PROVIDED?

YESNO

18. CERTIFICATION:

I, the applicant's authorized official, hereby certify that this application is prepared in conformity

with Title10, Code of Federal Regulations, and that all information provided is correct to the best

of my knowledge.

18a. PRINT NAME AND TITLE OF AUTHORIZED OFFICIAL

18b. SIGNATURE -- AUTHORIZED OFFICIAL

18c. DATE

PART E. TO BE COMPLETED FOR ALL LICENSES, AMENDMENTS, RENEWALS OR CONSENT REQUEST(S)

ADAMS ACCESSION NUMBER

NRC FORM 7 (11-2012)

U. S. NUCLEAR REGULATORY COMMISSIONNRC FORM 7

(11-2012)

10 CFR 110

Page

LICENSE NUMBER

DOCKET NUMBER

ADAMS ACCESSION NUMBER

PUBLICNON-PUBLIC

ADDITIONAL INFORMATION (Reference applicable block numbers from page 1 and/or page 2 for each entry)

APPLICATION FOR NRC EXPORT OR IMPORT

LICENSE, AMENDMENT, RENEWAL, OR CONSENT REQUEST(S) (Continued)

NRC FORM 7 (11-2012)

General Instructions: A completed, signed original NRC Form 7 may be mailed to the Deputy Director, Office of International

Programs, U.S. Nuclear Regulatory Commission, Washington, DC 20555-0001, or hand-delivered to the Deputy Director at 11555

Rockville Pike, Rockville, Maryland 20852.

Refer to Title 10 of the Code of Federal Regulations, Part 110, for specific NRC export/import licensing requirements. For each

license, amendment or renewal application, identify all foreign and domestic locations where exports or imports will be handled,

sorted, repackaged and/or processed in any way. Provide information on quantities, forms, and other characteristics of the

radioactive materials, sealed sources, nuclear facilities and equipment to be exported or imported and indicate how they will be

used by each of the parties listed. If more space is needed to complete any of the items on this form, use the continuation pages

first, and then attach additional sheets. Reference appropriate BLOCK number(s) for each entry on all additional sheets. All

applicants should avoid submitting proprietary information unless absolutely necessary, as NRC is required to make copies of all

applications received available to the public. If proprietary information must be submitted, follow procedures in 10 CFR 2.390,

otherwise, such information could be publicly disclosed and/or processing of an application could be significantly delayed.

U. S. NUCLEAR REGULATORY COMMISSION

INSTRUCTIONS FOR PREPARATION OF NRC FORM 7, APPLICATION FOR

NRC EXPORT OR IMPORT LICENSE, AMENDMENT, RENEWAL OR CONSENT REQUEST(S)

BLOCK 1. Enter name and complete physical address of the

corporation or other entity with direct control over distribution

of proposed export(s) or import(s), and where required

records will be maintained and can be inspected. Post Office

Box Numbers or names of divisions or departments within a

legal entity are NOT acceptable entries for this BLOCK.

BLOCKS 1a-e. Provide name and contact information

identifying the best party to answer questions about an

application. Applicants should use BLOCK 1b to assign their

own reference number to identify application documents.

BLOCK 2. Indicate the TYPE OF NRC LICENSING ACTION

requested by checking:

- AMENDMENT OR RENEWAL if applying to modify or

extend an export or import license previously issued by NRC

(and not yet expired). Include NRC license number in space

provided. If NRC receives an amendment/ renewal application

at least 30 days or more before the license expires, its terms

will remain valid and, if circumstances permit, it can continue

to be used until NRC completes action on the amendment or

renewal application.

-CONSENT REQUEST if submitting a request for the NRC to

obtain government-to-government consent to authorize

shipment(s) of Category 1 quantities of byproduct material.

Include NRC license number in space provided.

BLOCK 4. Enter the anticipated date of the first shipment

(MM/DD/YYYY).

PART C. TO BE COMPLETED BY APPLICANTS FOR

EXPORT LICENSES, AMENDMENTS, RENEWALS,

OR CONSENTS

BLOCK 7. Enter names of supplier(s) and other parties to

export not listed in BLOCKS 1, 8, OR 9. Provide complete

physical address(es) where correspondence should be sent

and where export(s) can be inspected. Post Office Box

Numbers are NOT acceptable entries for this BLOCK.

BLOCK 7a. Describe functions to be performed and/or

services to be provided by any parties listed in BLOCK 7.

BLOCKS 8-9. Enter names and physical address(es) for each

intermediate and each ultimate foreign location. Post Office

Box Numbers are NOT acceptable entries for these BLOCKS.

BLOCKS 8a and 9a. Describe how each consignee will use

export(s), including functions to be performed and/or services

to be provided.

BLOCK 10. Describe key characteristics including physical

and chemical forms, etc., of radioactive materials (i.e., source,

special nuclear or byproduct materials including sealed

sources or devices and radioactive waste), nuclear facilities

uranium, or thorium, and provide chemical form (e.g., U3O8,

Th-227). Identify and provide total volume in kilograms of ores

containing 0.05% or more of source material (e.g., tantalum,

niobium) and specify source material contained. Identify

special nuclear material as plutonium, high enriched uranium

(> 20% U-235) or low enriched uranium (<20% U-235) and

specify chemical form.

NOTE: FOR CONSENTS FILL OUT BLOCKS,

(1a-e,2,8,9,10,10a,17,18)

PART A. FOR NRC USE ONLY

PART B. TO BE COMPLETED BY ALL APPLICANTS FOR

ALL LICENSES, AMENDMENTS, RENEWALS, OR

CONSENT REQUEST(S)

NOTE: For amendments and renewals, provide only the new

or changed information, as appropriate, in PART C and/or

PART D. (For example, enter names and addresses of parties

or consignees, only if they need to be added to, deleted from,

or their information needs to be changed. If seeking to

increase the volume or quantity of material or equipment,

specify the additional increment, and, if applicable, indicate

what the new, combined cumulative total will be.)

- IMPORT if applying for a new import license.

- EXPORT if applying for a new export license.

BLOCK 3. If known, provide contract number(s), which may

be useful references for example, if reviewers need to contact

recipients or other parties listed on the application.

BLOCK 6. Enter a proposed license expiration date

(MM/DD/YYYY), to accommodate export activities. Note that

NRC licenses are typically issued for 1-5 years.

BLOCK 5. Enter the anticipated date of last shipment

(MM/DD/YYYY).

An application for a specific license to export or import or a request for an exemption from a licensing requirement must be

accompanied by the appropriate fee in accordance with 10 CFR Part 170. The fee schedules are provided in §§ 170.21 and

170.31. The reference “IMEX” should be included on your form of payment. A license application will not be processed unless the

specified fee is received.

BLOCK 15. Describe key characteristics including physical

and chemical forms, etc., of radioactive materials (i.e., source,

special nuclear or byproduct materials including sealed

sources or devices and radioactive waste), and nuclear

facilities. For radioactive waste, identify and provide maximum

total volume in kilograms for each non-radioactive material

(e.g., contaminated steel) involved, and physical and chemical

forms for each radioactive source, special nuclear or

byproduct material. Provide overall waste classification (see

10 CFR 61.55) if imported for direct disposal at a Part 61 or

equivalent Agreement State licensed facility; responsible

industrial process, route(s) of transit, and the status of

arrangements for disposition in the U.S., e.g., any agreement

by a low-level waste compact or State to accept for

management or disposal. For nuclear facilities, provide total

quantities; types; names, design power or annual capacity

rating; and the estimated combined total dollar value.

BLOCK 15a. For source and/or special nuclear material,

provide maximum total volume/element weight over license

life in kilograms. For Appendix L byproduct material, including

that which is in the form of radioactive waste, provide

maximum total activity over license life in TBq.

BLOCKS 15b-c. For special nuclear material including that

which is in the form of radioactive waste, provide maximum

enrichment/weight % and maximum total isotope weight over

license life in kilograms.

BLOCK 16. Identify each country and the percentage of the

maximum total volume that may be obligated to them (require

U. S. Government action, e.g., prior notification).

PART E. TO BE COMPLETED BY ALL APPLICANTS

BLOCK 17. Check YES or NO to verify whether or not

additional information is being provided using the space

provided on the continuation pages and separate sheets.

BLOCK 17a. Check YES or NO to verify whether or not

copies of domestic recipients' authorizations required for

Appendix P materials (see Part 110.32 requirements) are

included with the application.

BLOCKS 18a-c. An authorized official of the legal entity

applying for the License, Amendment or Renewal, must certify

Identify Appendix L byproduct materials by name and form,

including maximum total activities and types of sealed

sources and/or devices to be exported over the license life.

Identify Appendix P materials by name and form, including

maximum total quantities(activity in TBq) and types of sealed

sources and/or devices to be exported on a per shipment basis.

For radioactive waste, identify and provide maximum total

volume in kilograms for each non-radioactive material involved,

and physical and chemical forms for each radioactive material,

along with the overall waste classification (see 10 CFR 61.55)

if exported for the purposes of disposal in a land disposal

facility as defined in 10 CFR Part 61, a disposal area as

defined in Appendix A to 10 CFR Part 40, or an equivalent

facility; route(s) of transit, forms of management and ultimate

disposition. For nuclear facilities, provide total quantity; types;

names, design power or annual capacity rating; and the

estimated combined total dollar value. For nuclear equipment,

identify all items by name, total quantity and function and

provide the estimated combined total dollar value.

BLOCK 10a. For source material, provide maximum total

volume/element weight over license life in kilograms. For

special nuclear material, provide maximum total element

weight over license life in kilograms. For each Appendix L

byproduct material listed, provide maximum total activity over

license life in Terabequerels (TBq). For each Appendix P

material listed, provide maximum total activity per shipment in

Tbq.

BLOCKS 10b-c. For special nuclear material including as

radioactive waste, provide maximum weight % (enrichment)

and total isotope weight over license life in kilograms.

BLOCK 11. Identify each country and the percentage of the

maximum total volume that may be obligated to them

(requires U. S. Government action, e.g., prior notification).

PART D. TO BE COMPLETED BY APPLICANTS FOR

IMPORT LICENSES, AMENDMENTS OR RENEWALS

BLOCK 12. Enter name(s) and address(es) of foreign

supplier(s) or exporter(s).

BLOCKS 13a and 14a. Enter NRC or Agreement State

Materials License number(s) including expiration date(s)

(MM/DD/YYYY) for each U.S. consignee, authorizing receipt,

possession, use or distribution.

U. S. NUCLEAR REGULATORY COMMISSION

INSTRUCTIONS FOR PREPARATION OF NRC FORM 7, APPLICATION FOR

NRC EXPORT OR IMPORT LICENSE, AMENDMENT, RENEWAL OR CONSENT REQUEST(S) CONTINUED

BLOCK 12a. For import(s) originally exported under a specific

NRC license, enter that license number.