Personal information provided on this form is treated in confidence and in accordance with the Data Protection Act 1998. The information that you give will be used for the purposes of enabling the supply of personal radiation dose meters and the creation and maintenance of individual radiation exposure records. We may share information with selected third parties in fulfilling these obligations. Information will not be utilised or shared for any other form than for the purpose for which it is collected and will be kept securely within the terms of the Act.

Employer/Company Name

Department Name

Requested by?

Address (line 1)

Address (line 2)


Post Code

Telephone Number

Email Address
(this email address will receive the 1st copy report of Radiation Dosimetry Report and periodic usage summary reports)

Dosemeter Frequency
(tick appropriate)

Dosemeter Contact Name and Delivery Address
(if different from above)
Contact Name
Contact Address

Invoice Contact Name and Address
(if different from above)
Invoice Name
Invoice Address

Radiation Dosimetry Reports
Reports will be sent via e-mail only so please ensure an e-mail address is provided for each report recipient
Second Copy: Yes
Email Address:
Copy to RPA: Yes
Email Address:
Copy to RPS: Yes
Email Address:

Please complete to prove you are not a computer