APPLICATION TO BECOME AN APPROVED RPAS BROKER
To: The Director, CLEAPSS, The Gardiner Building, Brunel Science Park,
Kingston Lane, Uxbridge UB8 3PQ (e-mail )
Category of membership held: / Teacher Training Associate Member
Overseas Associate Member
Not-for-Profit Associate Member
Commercial Associate Member
Lead RPO
Name / ………………………………………………………………
Address: / ……………………………………………………………….
……………………………………………………………….
Postcode
Phone
E-mail / ……………………………………………………………….
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Names of all additional persons who will be acting as radiation protection officer(s) (RPOs): (note each identified person will need to have attend the CLEAPSS one day training session) Add more rows if necessary.
Name: / ……………………………………………………………….
Phone: / ……………………………………………………………….
Email: / ……………………………………………………………….
Name: / ……………………………………………………………….
Phone: / ……………………………………………………………….
Email: / ……………………………………………………………….
Name: / ……………………………………………………………….
Phone: / ……………………………………………………………….
Email: / ……………………………………………………………….
[The Applicant] [I] (delete as appropriate) wish to become an approved RPAS broker on the basis of the terms and conditions set out in section 8 of the CLEAPSS Membership Charter, a copy of which I have received.
I understand that by signing this application form I am accepting [for and on behalf of the Applicant] (delete if not applicable) the terms and conditions set out in section 9 of the CLEAPSS Membership Charter. I understand that, if this application is successful, [the Applicant] [I] (delete as appropriate) will be bound by those terms and conditions and I understand that they constitute the entire agreement in relation to all of [the Applicant's] [my] (delete as appropriate) brokerage activities. I hereby acknowledge that in submitting this application form [the Applicant] [I] (delete as appropriate) have not relied on any statement, promise or representation made by CLEAPSS or given on behalf of CLEAPSS that is not set out in this application form or the terms and conditions set out in section 9 of the CLEAPSS Membership Charter
Signed: ……………………………………………………………….
Applicant / Authorised Signatory for and on behalf of the Applicant (delete as appropriate)
Date: ……………………………………………………………….
GDPR
I understand that the information provided on this form will be stored and used by CLEAPSS for communications regarding membership and the associated services that I have requested.
May 2018
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