DICKEY-john Corporation Revolutionizing Electronics

Dewpointer General Licensee Record

Required for purchase of units containing Am-241

Company Name:
Company Address: Town:
State:   AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Zip: Country:
Specific License Required: No Yes License #
Customer Purchase Order No:

(Please provide your order number that was used to purchase product)

Contact person responsible for the safe installation and operation of the general licensee facility:

Name: Position:
Telephone: Extension:
Person Contacted (Supervisor): Position:
Data Taken By (Distributor, Buying agent): Date:

Check whether Americium 241 or Radium 226 is used.

Check One
Am-241 | Ra-226

Dewpointer Model Number: Serial Number:
Dewpointer Model Number: Serial Number:
Dewpointer Model Number: Serial Number:
Dewpointer Model Number: Serial Number:

Check One

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