Order Form for Existing Customers

Personnel Dosimetry Order form for existing customers

SECTION 1 – Your details

Please fully complete the form below to ensure the most efficient processing of your request. Account numbers and Series codes can be found printed on the reverse of any whole body dosimeter, printed on the label of any ring dosimeter, or on any dose report.

Name

Account Number (e.g. 712184)

Series Code (e.g. ABC)

Phone Number

Date

SECTION 2 – Change Details

Please complete the table below with the changes you wish to be made to your current participant list.

Please complete ALL of the columns below / Only complete these columns when adding new participants
Type of Change (Add, Delete, Name Change) / Surname (include previous surname if changing) / *Forename / Sex M/F / Type of dosimeter (see table below) / Body Region / Size (if applicable) / Date of Birth / Date first dosimeter is required (dd/mm/yy or ASAP)
Add / Smith / John / M / U / Right Finger / M / 01/01/00 / 01/01/17

Dosimeters Available

Dosimeter Type / Body Region / Sizes available
Pa / Whole Body / N/A (one size fits all)
U / Left Finger / S/M/L/XL
U / Right Finger / S/M/L/XL
U / Left Fingertip / S/M/L/XL
U / Right Fingertip / S/M/L/XL
U / Left Wrist / S/M/L/XL
U / Right Wrist / S/M/L/XL
U / Eye / N/A (one size fits all)

SECTION 3 – Additional Information and Declaration

IRS will process this form in accordance with its formal Quality processes and procedures. It is the responsibility of the person completing this form to ensure that all information provided is accurate. The provision of incorrect data may result in errors occurring with the supply of dosimeters.

Change Deadline – This is the date by which all changes must be made in order for them to be processed in time for your next regular shipment of dosimeters. The Change Deadline is detailed on the Packing List that is sent with your regular delivery of dosimeters.

Please note, anyrequests to remove dosimeters from your account that are received after a Change Deadline has passed will not be reflected in your next routine delivery. You will still receive the cancelled dosimeters and you will be charged for them.

Additional dosimeters that are requested after a Change Deadline will be sent by IRS as ‘Spare’ dosimeters and may not display the participants name or the correct wear period date. These badges will be sent in time for the next routine wear period, but are likely to be delivered separately to your regular delivery.

Confirmation – Pleaseconfirm you have read and understood the information supplied within this form by signing and dating below:

Signature:Date:

Return this form to IRS Ltd

Please return this form to IRS’s Personal Dosimetry Department via email

Alternatively, this form can be faxed to 0151 709 8772 or posted to:

IRS Ltd

Unit 188, Century Building

Tower Street

Liverpool

L3 4BJ