www.esr.cri.nz
NATIONAL CENTRE FOR RADIATION SCIENCE
LABORATORY SERVICES REQUEST FORM
RADIOACTIVITY CERTIFICATE
CONTACT DETAILS
CERTIFICATE DETAILS
A certicate will not be issued unless the following information is provided and is clearly legible.
All information provided in this section will be exactly duplicated on the certicate.
If an additional statement is requested, documentation may be required. Please contact ESR for further information. ESR can also assist if a
certicate requires translation.
Contact name:
Alternative title for certicate (if required):
Company:
Goods description and quantity:
Exporters name and address:
Letter of credit number (if applicable): Other identifying number:
Shipping details:
Final destination:
Customer declaration (if required):
Street address:
Postal address: Post code
Phone number: Mobile:
Email address:
RESET FORM
ESR USE ONLY
AOAD:ESR number:
INSTRUCTIONS FOR USING FILLABLE FORMS: In Acrobat
Reader, please complete this form, then save the pdf to your
hard drive. Email this form to
ncrs.environmental@esr.cri.nz
ESR0328
vers 4.0 FEB 2017
INSTITUTE OF ENVIRONMENTAL SCIENCE AND RESEARCH LIMITED
NATIONAL CENTRE FOR RADIATION SCIENCE, Christchurch Science Centre: 27 Creyke Road, Ilam, Christchurch 8041 | PO Box 29181
Christchurch 8540, New Zealand T: +64 3 351 6019 F: +64 3 351 0010
DECLARATION
I declare this product is of 100% New Zealand origin. YES NO (A certicate will not be issued unless this declaration is made)
If no, the goods must be tested for radioactivity content – please also complete a Testing of Foodstuffs request form.
Name and position: Date:
I agree to pay the charges incurred in obtaining this certicate
ADDITIONAL INFORMATION
Is courier despatch required? YES NO If yes, there will be an extra charge. If no, certicate(s) will be delivered by FastPost.
A certicate will be issued within 2 working days after receipt of a request.
Number of additional copies (Additional copies are an extra charge).
Purchase order number:
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