| Special Instructions: |
Sections A-B to be completed by LVS Help Desk (if applicable). Sections C-D to be completed by the licensee: Complete sections C and D below for NRC or Agreement State licensees needing to verify a license outside of the License Verification System. For issues with submitting this form, please contact the LVS Help Desk: 1-877-671-6787 or E-mail: LVS Help Desk.
Sections E-F instructions (Agency representative to provide): Verify the information in Section D above and make sure that all information provided is valid and the authorized location, materials and quantities being requested are authorized on the recipient's license. Record the verification outcome below. Return the completed form via e-mail to the LVS Help Desk.
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