F A I R F A X R A D I O L O C Y

IF MCI I C E K N T E R s J

K U \ I h I 55 c kh 1 I I: 2722 MERRILEE DRIVE SUITE230 FAIRFAX VA22031 703-698 4444 FAX 703-698-2176

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h l C LL\Kh\I [)IC IN1 ILt\GlN<, CLh I tl: 3299 WOODBURN RD SUITE 110 ANNANDALE VA22003 703 849-9050 FAX 703 698-4491

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\ I O R h l 0 \ 2 N 1&24(1lNOC t V I I f I 8316 ARLINGTON BLVD, SUITE 206 FAI RFAX VA 22031 703-698-8550 FAX 703-641-5709

I’KO\l’kf:[n I \ l A C i l h C ; L t h l t K 8503ARLlNGTON BLVD LL-SUITE 100 FAIRFAX VA 22031 703-698-9600 FAX 703-698-5609

i t i t L I ~ ~ I L I W N ~ ~ R CthItR 8S03ARLINGTON BLVD. LL-SUITE 100 FAIRFAX VA22031 703-698 4498 FAX703-2WIS66

l t i l KRlZ\TO14C~NO\lIC C t h I t I< 8318ARLlNGTON BLVD SUITE200 FA1 RFAX VA 22031 703-698-4455 FAX 703-205-9884

f ? I K f ~ \ ~ t l : l ~ L v l l i ~ 8318 ARLINGTON BLVD SUITE 100 FA1 RFAX VA 22031 703 204-8333 FAX 703 204-3744

L I t N N 4 I,\\ \C; I UG C t hTE K 115 PARKSTREFT SE. SUITE 300 VlENNAVA22180 703-698-4456 FAX 703-242-4474

sl’KIN(;FILLII lbtrZC>lN(>C I \ I L K 5510 ALMA LANE. SUITE 100 SPRINGFIELD, VA221S1 703-698-4485 FAX 703-7Y30302

KL\TOh t l l I < N l > O h

100 ELDEN STREET SUITE 16 HE RN DON, VA 20170 703-48-9400 FAX 703-481-9408

I M , \ ~ ; I ~ C , C I ~ I ~ R

R t 5 J O N I l l l < V I I O N

106 ELDEN STREET SUITE 16 HERNDON VA20170 703-481-9400 FAX 703-796-1103

H K F A ~ ~ i\ti\c,ihcr c N ~ I K

C t h l K I \ l l l t CL I I ION I&~\CIINCI C t V I t R 6211 CENTWILLE RD SUITE 400 CENTWILLE VA 20121 703-204-4411 FAX 703-961-8318

\ $ t \ l t R h lOlllXNlh I h t A(; I N( I C f U 1 I R 224 CORNWALL STREET, NW LEESBURG, VA20176 703-737-7550 FAX 703-737-7555

FAIRFAX RADIOLOGICAL CONSULTANTS, P.C. RADIOLOGISTS TO INOVA FAIRFAX HOSPITAL

A N D LOUDOUN HOSPITAL CENTER

September 27,2005

h)

Nuclear Regulatory Commission, Region I Licensing Assistance Team

475 Allendale Road

- I Division of Nuclear Materials Safety

King of Prussia, Pa. 19406- 14 15

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G RE: AMENDMENT TO NRC LICENSE NO. 45-25031-01 0 2 0 3 m L -

Encl: NRC Form 3 13 - Amendment Request Floor Diagram of New FRC Suite and Nuclear Medicine Clinic

To Whom It May Concern,

FRC is planning on moving the current nuclear medicine clinic to a new location and this request is for the approval of the new nuclear medicine space. Once the move is complete, the previous nuclear medicine clinic will be decommissioned and returned to general use. Once the new space is approved and new camera(s) are installed, it will become operational and the old clinic will start to shut down. For a short period of time both clinics may be in operation. The old space will become inactive when the camera(s) have been moved. The old clinic space will undergo decommissioning once all activity has ceased. Specific information is provided below.

Old Location: Fairfax Radiological Consultants, P. C. 3299 Woodburn Road Suite 110 Annandale, VA 22003

New Location: Fairfax Radiological Consultants, P.C. 8503 Arlington Boulevard Suite LLlOO Fairfax, VA 2203 1

Description: See attached diagram of the space. The nuclear medicine clinic is part of the FRC Radiological Suite being installed at this location. The suite occupies the entire floor with nuclear medicine being located in the northeast corner. FRC controls all spaces adjacent to the clinic except for the adjacent hallway which is used for deliveries. The clinic consists of three imaging rooms, a thyroid uptake room, a patient bathroom, changing rooms, a central technician work

137 8L3 NMSSmGNl MATERIALS902

‘FAIRFAX MRI CENTER I S OWNED BY INOVA FAIRFAX HOSPITAL MANAGEMENT AND PROFESSIONAL SERVICES ARE PROVIDED BY FAIRFAX RADIOLOGICAL CONSULTANTS. PC

\ \- \ \~\- .ki i h s r a d iology . c-oni

F A I R F A X R A D 1 0 L O G Y

FAIRFAX RADIOLOGICAL CONSULTANTS, P.C. RADIOLOGISTS TO INOVA FAIRFAX HOSPITAL

AND LOUDOUN HOSPITAL CENTER

IF MCI I C E N T E R S I

Description (continued): I W I ~ ~ \ ~ L I ~ I F R 2RZMERRlLEE DRIVE SUITE230 FAlWAXVA22031 703-698-4444 FAX 703-698-2176

\ L C K I l ) H C RN 1 1 1 4 C ~ N O f I l ( CL U1 t R N CJC 1 FAR \ t I 111 C I \ t I h\ ZC, I VCo c t N r i K 3299 WOODBURN RD SUITE 110 ANNANDALE VA22003 703-849-9050 FAX 703-698 4491

l O R h l O \ \ N IhtA(xINC, Ct N I I K 8316ARLINGTON BLVD SUITE 206 FA1 RFAX VA 22031 703-698-8550 FAX 703-641 5709

PRO\l'FRI n IA1AOING C t\l 1 tl: 8503ARLlNGTON BLVD LL-SUITE 100 FAI RFAX VA 22031 703-698-9600 FAX 703-698-5609

I

rtir I I I r i v , j o ( i N i i Crr , r t r i 8503ARLlNGTON BLVD. LL-SUITE 100 FA1 RFAX VA 22031 703-698-4498 FAX 703-2801566

8318ARLlNGTON BLVD. SUITE200 FA1 RFAX VA 22031 703-698-4455 FAX 703-205-98&

FAIRf A\ A\KI ('I h I I l l 8318 ARLINGTON BLVD, SUITE 100 FAIWAX VA22031 703-204-8333 FAX 703-204-3744

I '

VIFUN4 I,\lr\C,l\G C F h l LR 115 PARKSTRE!Z SE. SUITE 300 VIENNA VA22180 703-698-4456 FAX 703-242-4474

\ P K l h ( ~ ~ l f l I ~ l ~ t Z ( ~ l h G ( l U l l l < 1 5510AlMA LANE SUITE 100 SPRINGFIELD VA22151 703-698-4485 FAX 703-750-0302

R L \ I O \ I l l I:uI)C)v 14t4CjINC, ( tN1 I K 100 ELDEN STREET SUITE 16 H E R N W N VA20170 703-481-9400 FAX 703 423-9408

R t s I O U t i t I:UIION BRIA51 l 'vt4C~lNC~C t N l t K 106 ELDEN STREET. SUITE 16 H E R N W N VA20170 703-48-9400 FAX 703-796-1103

C ~ \ ~ R L L I I I I ( I I I I O ~ I A4 ZC! I \ ( J c t h T t I: 6211 CENTREVILLE RD SUITE 400 CENTREVILLE. VA20l21 703-204 4411 FAX 703-961-8318

area, radiopharmacy and a separate injection room. The radiopharmacy has a sink, a small lead shielded area for the storage of the dose calibrator check sources and has a lead shielded 'z" block with a leaded window for manipulation of radioactive doses. The sink is for hand washing, as no radioactive material will be disposed of through the sewer system. The clinic uses only unit doses supplied by a licensed commercial radiopharmacy. The doses are delivered to and stored in the radiopharmacy. All doses will be stored in their leaded shipping shields until used and the empty syringe will be returned to the shipping shield for return to the vendor. Each source will be assayed in a dose calibrator.

At this time we are requesting that the following additional authorized users be added :

Phvsicians Name Kara M. Beckner, MD Elise L. Berman, MD Leslie A. Bord, MD Rodney J. Butch, MD J.Richard Choi, MD Charlene A. Curry, MD James P. Earls, MD Eric R. Gorny, MD Bernice D. Griffith, MD Kathryn Grumbach, MD Gary M. Kellman, MD Cheryl A. Lindstrom, MD Kurosh Majd, MD Steven A. Meyers, MD Sameena F. Nasrullah, MD Robert S. O'Connell, MD Daniel L. Overdeck, MD Yvonne S. Sim, MD Bruce A. Urban, MD Michael J. Varanelli, MD

35.100 X X X X X X X X X X X X X X X X X X X X

35.200 35.300 35.500 X X X X X X X X X X X X X X X X X X X X

The above radiologists are all board certified in radiology by the American Board of Radiology (copies enclosed).

\ m i t I:N I O ~ I I X ~ L I N IMA(,IN~, c t Y r 1 I< 224 CORNWALL STREET NW LEESBURG VA20176 703-737-7S50 FAX 703-737-7555

'FAIRFAX MRI CENTER IS OWNED BY INOVA FAIRFAX HOSPITAL MANAGEMENT A N D PROFESSIONAL SERVICES ARE PROVIDED BY FAIRFAX RADIOLOGICAL CONSULTANTS rc

~ v u x ~ . ~ i i l - ~ i s r - ~ i c l i o l o g ) . . cotn

F A I R F A X R A D I o L o G Y

IF MCI I C E N T E R S I

t i C I $ I N t \ 5 C F N I t R 2722 MERRlLEE DRIVE, SUITE 230 FAIRFAXVA22031 703 698-4444 FAX 703-698-2176

\ \CXll) l \C 'KN i>i4c;wn I IC c th rt R NIK ~t \ i ~ d i t r ~ ~ i ~ \ t i \ i , w u , C L N l t K 3299 WOODBURN RD SUITE 110 ANNANDALE VA22003 703 849-9050 FAX 703-698 4491 1

8316 ARLINGTON RLVD, SUITE 206 FAI RFAX VA 22031 703-698-8550 FAX 703-64-5703

riwwtiu I \ I M ~ G I N G C L U I i K 8S03ARLINGTON BLVD LL-SUITE100 FA1 RFAX VA 22031 703-698-9600 FAX 703-698-5609

TIIF I I L I fL\\CNlh 1) C E N I t K 8503ARLlNGTON RLVD. U-SUITE 100 FAIRFAX VA22031 703-698-4498 FAX 703-28@1566

TI I I L i R t U I I ) 1 2 C r l O \ I I C C C N I I I I 8318 ARLINGTON RLVD SUITE 200 FAI RFAX VA 22031 703-698-4455 FAX 703 205-9884

l ~ \ l K F ; \ \ \ \ l < l C I N l I I 1 ' 8318ARLlNGTON BLVD SUITE 100 FA1 RFAX VA 22031 703-204-8333 FAX 703-204-3744

\ I E l U 2 Id14ClNO C I N I I K 115 PARKSTREET SE SUITE300 VIENNkVA22180 703 698 4456 FAX 703-242 4474

S ~ l ~ I N ~ ~ F I t L I ~ I ~ . t ~ C ~ I h l ~ ~ ( _ I h l t K 5510AUlA LANE. SUITE 100 SPRINGFIELD. VA 22151 703-698-4485 FAX 703-750-0302

K t 5 1 O l ti I I<\ 1 > 0 \ Iht \ ( r INO Cl N I t K 100 ELDEN STREET SUITE 16 HERNDON VA20170 703-481-9400 FAX 703-48-9408

K [ \ T O Y t l f 11VI)OW K K t 4 ( 1 I \ t A C i l h G C t N l t K 106 ELDEN STREET SUITE 16 HERNDON VA20170 703-481 9400 FAX 703-796 1103

ct N I R t \ i t 1 t c I i f r o l IM K,IUL ct \ r f I: 6211 CENTREWLLE RD SUITE 400 C E N T W LLE VA 20121 703-204-4411 FAX 703-961-8318

\ $ F $ l t Kh L 0 l I l ) O l l h

224 CORNWALL STREET NW LEESBURG. VA20176 703-737-7550 FAX 703-737-7555

Ict4cLihic,c t N n I:

FAIRFAX RADIOLOGICAL CONSULTANTS, P.C. RADIOLOGISTS TO INOVA FAIRFAX HOSPITAL

AND LOUDOUN HOSPITAL CENTER

We are also requesting that our Radiation Safety Officer be changed from Michael G. Velchik, MD to Brigid Anne Castro, MD. Dr. Castro is currently listed as an authorized user on our license.

All other elements of the current license will remain in effect at the new clinic. If there are any questions concerning this request, please contact me at (703) 698- 4444.

Sincerely,

BrigiduA. Castro, MD Treasurer

'FAIRFAX MRI CENTER IS OWNED BY INOVA FAIRFAX HOSPITAL MANAGEMENT AND PROFESSIONAL SERVICES ARE PROVIDED BY FAIRFAX RADIOLOGICAL CONSULTANTS PC

\n-w. f i t irkisrad iology . c ~ i ~ n

RC FORM 313 U.S. NUCLEAR REGULATORY COMMISSION -2004) I CFR 30 32 33

35 36 39 and40

RAD1 OACTIV E MATERIAL a Ekment and m a s number b chemical andlor physical form and c malrlmum amount

which WIII be possessed at any one time

APPLICATION FOR MATERIAL LICENSE

6 PURPOSE(S) FOR WHICH LICENSED MATERIAL WILL BE USED

APPROVED BY Om: NO. 31SWl20 EXPIRES: 10/31/200 Est imated burden per response to comply w i th this mandatory collection request hours Submittal of the application IS necessary to determine that t h e applicant

ualified and that adequate procedures exist to protect the public health and safet ze nd comments re rding burden estimate to the Records and F O I N R i v a c y Servia Branch r - 5 F52), 13"s Nuclear Regu la tov Commission Washington Dc M555-0M3' or by in ternet e-mail to in focol lects nrc o v and to the Desk Off lcer Of f ice [

Information and Regulatory Affairs NE%B-l8M2 (3150-0120) m c e of MaMgefM?l and Budge t Washington DC 20503 If a means used t o impose an informat lo collection Goes not display a currently Valid OMB control number the NRC may rn conduct or sponsor and a person IS not required t o respond to the in format lo ml lect ion

IISTRUCTIONS: SEE THE APPROPRIATE LICENSE APPLICATION GUIDE FOR DETAILED INSTRUCTIONS FOR COMPLETING APPLICATION. END W COPIES OF THE ENTIRE COMPLETED APPLICATION TO THE NRC OFFICE SPECIFIED BELOW

PPLICATION FOR DISTRIBUTION OF EXEMPT PRODUCTS FILE APPLlCATlONS WITH ' IF YOU ARE LOCATED IN

DIVISION OF INDUSTRIAL AND MEDICAL NUCLEAR SAFETY OFFICE OF NUCLEAR MATERIALS SAFETY AND SAFEGUARDS J S NUCLEAR REGULATORY COMMISSION WASHINGTON DC 22555-0031

,L OTHER PERSONS FILE APPLICATIONS AS FOLLOWS:

YOU ARE LOCATED IN:

LABAMA, CONNECTICUT, DELAWARE DISTRICT OF COLUMBIA. FLORIDA, GEORGIA. ENTUCKY. MAINE. WRYLAND. MASSACHUSETTS, MISSISSIPPI, NEW HAMPSHIRE. N M XSEY. NNYYORK, NORTH CAROLINA. PENNSYLVANIA. PUERTO RKO. RHODE LAND. SOUTH CAROLINA. TENNESSEE VERMONT. VIRGINIA. VIRGIN ISLANDS, OR EST MRGINIA. SEND APPLICATIONS TO:

LICENSNG ASSISTANCE TEAM DIVISION OF NUCLEAR MATERIALS SAFETY U S NUCLEAR REGULATORY COMMISSION REGION I 475ALLENDALE ROAD KINGOF PRUSSIA PA 194C61415

ILLINOIS, INDIANA. IOWA. MICHIGAN. MINNESOTA, MSSOURI. OHIO. OR WISCONSIN. SEW PlPPLlCATlONS TO

MATERIALS LICENSING BRANCH U S NUCLEAR REGULATORY COMMISSION REGION II 2443 WARRENVILLE ROAD SUITE 210 LISLE IL 60532-4352

ALASKA. ARIZONA. ARKANSAS CALIFORNIA. COLORADO, HAWAIL IDAHO. KANSAS, LOUISIANA. MONTANA NEBRASKA, NEVADA. NEW MEXICO. NORTH DAKOTA. OKLAHOW OREGON. PACIFIC TRUST TERRITORIES SOUTH DAKOTA TEXAS, UTAH, WASHINGTON, OR WYOMNG. SEN0 APPLICATIONS TO:

NUCLEAR MATERIALS LICENSING BRANCH U S NUCLEAR REGULATORY COMMISSON REGION IV 611 RYAN PLAZA DRIVE SUITE 400 ARLINGTON TX 76011-4005

6 3 0 30% b ERSONS LOCATED IN AGREEMENT STATES SEND APPLKATIONS TO ME U.S. NUCLEAR REGULATORY COMHISSION ONLY IF THEY-WISH TO POSSESS AND USE LICENSED ATERIAL IN STATES SUBJECT TO U.S.NUCLEAR REGULATORY COMMSSION JURISDICTIONS

THIS IS AN APPLICATION FOR (Check appoprwte em) 0 '1FiZ -1CENSE

AMENDMENT TO LICENSE NUMBER 45-25031-01 -

0 C RENEWAL OF LICENSE NUMBER ~

ADDRESS WERE LICENSED MATERIAL W ~ L BE USED OR POSSESSED

Fairfax Radiological Consultants,P C 8503 Arlington Blvd Suite LL100 Fairfax. Va 22031

2 NAME AND MAILING ADDRESS OF APPLICANT (Include ZIP code)

Fairfax Radiological Consultants,P C 2722 Merrilee Drive Suite 230 Fairfax, Va 22031

4 NAME OF PERSON TO BE CONTACTED ABOUT THIS APPLICATION

Brigid A Castro, M D - -

TELEPHONE NUMBER

(703) 698-4444

18 TRAINING FOR INDIVIDUALS WORKING IN OR FREWENTING RESTRICTED AREAS iNDlVIDUAL(S) RESPONSIBLE FOR RADIATION SAFETY PROGRAM AND THEIR TRAINING EXPERIENCE

FACILITIES AND EQUIPMENT I 10 RADIATION SAFETY PROGRAM

12 LICENSE FEES (See 1OCFR 170andSecfon 170311

FEE CATEGORY 7-Medical Use - ~ F ; " c ~ ~ ~ E D s ~

1 WASTE MANAGEMENT

-~ ~- ~~- --

3 CERTIFICATION s^r T ,=&OD, -$f.T

(nrusrse mmpked by applranf) THE APPLICANT UNDERSANDS THAT ALL STATEMENTS AND REPRESENTATIONS MADE IN THIS APPLICATION ARE BINDING

THE APPLICANT AND ANY OFFICIAL EXECUTING THIS CERTIFICATION ON BEHALF OFTHE APPLICANT NAMED IN ITEM 2 CERTIM'HAT -HIS APPLICATION IS PREPARED IN CONFORMITY WlTH TITLE 10 CODE OF FEDERAL REGULATIONS PARTS 30 32 33 34 35 36 39 AND 40 AND THAT ALL INFORMATION CONTANED HEREIN IS TRUE AND CORRECT TO THE BEST OF THEIR KNMNLEDGE AND BELIEF

WARNING ANY DEPARTMENT OR AGENCY OF THE UNITED STATES AS TO ANY MATER WTHlN ITS JURISDICTION

18 U S C SECTION 1001 ACT OF JUNE 25 1948 62 STAT 749 MAKES IT A CRIMINAL OFFENSE TO MAKE A WLLFULLY FALSE STATEMENT OR REPRESENTATION TO

~ - ~~ ~

DATE ERTIFYING ~FFICER -- WEDPRINTED NAME AND TITLE

3rigid A. Castro, MD - Treasurer FOR NRC USEQNLW ______

i > l P 4 , 9

Y'PE OF FEE FEE LOG I PPROVED a y

3 PRINTED ON RECYCLED PAPE

15 I3b NRC FORM 313 (4-2004)

NMSSlRGNl MATERIA^

ITEM 5 RADIOACTIVE MATERIAL

NO CHANGE - As currently listed in the license.

ITEM 6 PURPOSES FOR WHICH MATERIAL WILL BE USED

NO CHANGE - As currently listed in the license.

ITEM 7 & 8 INDIVIDUAL RESPONSIBLE FOR RADIATION SAFETY PROGRAM AND THEIR TRAINING EXPERIENCE

Brigid Anne Castro, MD will be replacing Michael George Velchik, MD as the RSO.

License #45-2503 1-0 1

ITEM 9 FACILITIES AND EQUIPMENT

FACILITY DIAGRAM: The facility is located on the ground floor of a multistory office building and is part of the FRC Radiological Suite which occupies the entire floor. The Nuclear Medicine Clinic area is located in the northeast corner bounded on two sides by the external walls of the building which is a masonry construction and by a hallway and an x-ray room. The clinic consists of three imaging rooms, a radiopharmacy, a thyroid uptake room, patient injection area, bathroom, patient changing rooms, and a small dedicated patient sitting area. Access to the clinic is via a controlled hallway accessed from the general patient waiting area via the reception desk. The radiopharmacy consists of a nonporous countertop, sink, cabinets, and an area for radioactive waste storage. The radiopharmacy area can be locked separate from the rest of the clinic spaces.

RADIATION MONITORING INSTRUMENTS: The clinic will have three nuclear gamma cameras for imaging patients - one new unit and two moved from the old site. All other equip- ment is as stated in the current license.

DOSE CALIBRATOR: The Nuclear Medicine Clinic uses only unit doses provided by a licensed Nuclear Pharmacy or radiopharmaceutical manufacturers. The primary method of verifying activity of each dose will be by use of a dose calibrator, Capentec Model 30, SN 70969. In the event of unavailability of the Dose Calibrator the clinic will rely on the recorded activity (adjusted for decay) provided by the radiopharmacy andor radiopharmaceutical manufacturer providing the unit dose.

The dose calibrator will be calibrated in accordance with nationally recognized standards or the manufacturer’s instructions.

This is as currently being done.

OTHER EQUIPMENT AND FACILITIES: The new clinic will have additional safety equip- ment consisting of syringe shields, vial shields, a lead shielded “L” block with leaded window to manipulate unshielded syringes, forceps for handling unshielded RAM as appropriate, lab coats and disposable gloves. Lead lined RAW containers are available and a decontamination kit is available to handle contamination events should they occur. All unit doses are received in lead syringe “pigs.” Single use aerosol trap kits are used for aerosol lung imaging.

License #45-2503 1-0 1

ITEM 10 RADIATION SAFETY PROGRAM

AREA SURVEYS: Area surveys will be implemented in the new spaces in accordance with 10 CFR 20.1 101 that meet the requirements of 10 CFR 20.1501 and 10 CFR 35.75. This is the same as is presently being done.

OCCUPATIONAL DOSE: NO CHANGE - As currently listed in the license.

MINIMIZATION OF CONTAMINATION: NO CHANGE - As currently listed in the license.

SAFE USE OF UNSEALED LICENSED MATERIAL: NO CHANGE - As currently listed in the license.

SPILL PROCEDURES: NO CHANGE - As currently listed in the license.

ITEM 11 WASTE MANAGEMENT

NO CHANGE - As currently listed in the license.

License #45-2503 1-01

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This is to acknowledge the receipt of your letterlapplication dated

16\13h 0 6 , and to inform you that the initial processing which includes an administrative review has been performed.

hmecidrru-f- ~%5-&563 1-01 There were no administrative omissions. Your application was assigned to a technical reviewer. Please note that the technical .review may identify additional omissions or require additional information.

c] Please provide to this office within 30 days of your receipt of this card

A copy of your action has been forwarded to our License Fee 8 Accounts Receivable Branch, who will contact you separately if there is a fee issue involved.

Your action has been assigned Mail Control Number I 3 78 6 3 . When calling to inquire about this action, please refer to this control number. You may call us on (610) 337-5398, or 337-5260

NRC FORM 532 (RI)

(SW Sincerely, Licensing Assistance Team Leader