Ref. No.		
Details about the material	
	
Batch number:		Item identifier:		Material category:			
	
Materials Balance Area:		Any attributed Country obligation?
(leave blank if Nil)			
	
Physical form:		Is this material irradiated?		
	
Chemical form:		Material Description Code:			
	For  enriched  uranium	
Element Weight:		Kg	
Grams		235U grams		233U grams:			
	
Details about the change in disposition
	
Describe the planned changes - compare current disposition versus new / proposed:	

		
	
Describe why the new disposition will make the material 
un-verifiable:	

		
	
Explain / justify why this change is required:	

		
	
Proposed date of change:			

Applicant’s signature, and permit details	ASNO use only	
	Approved:	____/____/______

For Director General ASNO	
Name :				
		
Position:				
Signature:	___________________________	Date:	____/____/________		
	
Name of Permit Holder:		Permit number:			

Explanatory Notes

Ref No		A sequential reference number is required for each form of this type submitted by the Permit Holder (eg 001, 002, 003 etc). Where amendments are made to a previously submitted form, please use the same reference with a sequential revision number (eg 2005-003 Rev 1).	
Material category		Examples are natural uranium, enriched uranium, heavy water, etc.	
Details about the change in disposition		
Include a likely date for changing the disposition back to a state where the material can be verified for safeguards purposes.	
Proposed date of change		
A change in disposition must not be implemented prior to approval being granted.  Note that approvals are typically returned within 14 working days after receipt of the application.	
Applicant’s signature		This form must be signed by a representative of the Permit Holder (ie, the organisation) who will take responsibility for, and sign documents on behalf of, the organisation.	

This form replaces the following forms 	ASO128 (issued 1 January 2002)