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Ss: Directorate: Radiation Control, Private Bag X62, Bellville, 7535 Street Address: 2nd Floor, Louwville Place, cor. Vrede & Kort St., Bellville, 7530 Enquiries: Tel: 021 - 948 6162 Fax: 021 - 946 1589 A: PRIMARY IMPORTER - APPLICANT Name: Postal Address: Street Address: Postcode: Website: B: PRODUCT INFORMATION Brand: Model: Intended purpose of this device according to the manufacturer’s labelling and instructions for use: C: MANUFACTURER Name: Address: Website: D: AUTHORISED REPRES.

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