ࡱ> KNJy V3bjbj 4:{{d)88888LLL84\L"NbbbbzL\(0"2"2"2"2"2"2"$$u'NV"E8V"88bb4"L8b8b0"0": ,L!bpD+F ""0" R'd'L!'8L!V"V"z"' :  Personal Information: Last Name:  FORMTEXT       First Name:  FORMTEXT      Gender:  FORMCHECKBOX  Male  FORMCHECKBOX  FemaleJob Title:  FORMTEXT      Department:  FORMTEXT      Office Location: Building:  FORMTEXT       Office #:  FORMTEXT      Phone #: FORMTEXT       Email:  FORMTEXT      24 hour contact information for emergency purposes (ONLY for Internal Permit Holder and Radiation Laboratory Supervisor): Home:  FORMTEXT       Cell:  FORMTEXT       Alternate: Home:  FORMTEXT       Cell:  FORMTEXT       Training: University of Winnipeg Radiation Safety Training Course Date:  FORMTEXT      Other Radiation Safety Training (Organization, date and length):  FORMTEXT        Consent: I hereby agree to work in a responsible and reasonable manner, in accordance with the University of Winnipeg policies and procedures. I am aware that the Canadian nuclear Safety Commission has the authority to fine me personally if I do not comply with the University of Radiation Safety manual (as of July 3, 2013). I agree to be designated by the University of ̳ as a:  FORMCHECKBOX  Permit Holder  FORMCHECKBOX  Authorized Worker  FORMCHECKBOX  Authorized Nuclear Energy Worker Signature of Registrant: __________________ Date: ______________  Authorization from the Permit Holder: As the permit holder, I request that the following person to be added to my internal permit(s). *,.0FH\^`jlvx   , 0 F H \ ^ ` j l n ѲܪܜѲѪ܎܀ܪrѲѪnhI.jhVoBhI.UjhVoBhI.UjhVoBhI.UjthVoBhI.Uh /hI.5 jhVoBhI.UmHnHujhVoBhI.UjhVoBhI.U hVoBhI. hw%85 hW5 hJj5hVoBhVoB5 h_v5+.0x. 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It is collected to register and contact workers. Telephone numbers are collected for emergency purposes and will be shared only with Security Services and the Safety Office. 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Text1Text2Check1Check2Text4Text8Text9Text10Text17$If1P6[vCbcdfgijlmopdfgijlmop^hZcdp^hZcdfgijlmop/0R_/ tvh^`OJQJo(hHh^`OJQJ^Jo(hHohp^p`OJQJo(hHh@ ^@ `OJQJo(hHh^`OJQJ^Jo(hHoh^`OJQJo(hHh^`OJQJo(hHh^`OJQJ^Jo(hHohP^P`OJQJo(hH^`o(. ^`hH. pL^p`LhH. @ ^@ `hH. ^`hH. L^`LhH. ^`hH. ^`hH. PL^P`LhH./_/          e        .,_v@ fgI.!S3w3)z/:0s6w%8os8VoBq |^f?w w`+hJj[3YNd /WO;aRWxRdf@@HH HH @H.UnknownG*Ax Times New Roman5Symbol3. *Cx Arial7.@Calibri5. .[`)Tahoma?= *Cx Courier New;WingdingsA$BCambria Math"hfW'fW'1p p !r0aa KQHP  $PVoB2!xx Shah-Sa Kevin Smith  Oh+'00x   (Shah-SaNormal Kevin Smith2Microsoft Office Word@F#@z<@+@+p՜.+,0 hp  the University of ̳ a  Title  !"#$%'()*+,-./0123456789;<=>?@ACDEFGHILMPRoot Entry F`G+OData 1Table&'WordDocument 4:SummaryInformation(:DocumentSummaryInformation8BMsoDataStore+pD+LHQ040CDLPQ==2+pD+Item  PropertiesUCompObj r   F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q