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G permission) 1. Institution No. allotted by AERB : 2. Name & address of the Institution : 3. Contact details of the Medical Physicist, who has carried out the acceptance tests: (a) Telephone No.(with STD code) : (b) Fax No. : (c) e-mail : 4. Details of the Radiation Therapy Unit to be commissioned for patient treatment: Make and Model of the unit Sr.No. of the unit Existing Source Strength (Ci, RMM, MV, MeV) I hereby undertake that, I have carried out performance/acceptance test o.

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