Fifth Schedule, Environment Protection Agency Act, 2008

(Section 46) FORM A Application Form for Permit to import controlled substances/controlled products (One application shall be used for each group of controlled substance) Name of applicant:............................................................................................................... Address (business):............................................................................................................. Address (residential):…………………...............………………………………………. Passport No:…………………………...............…………………………………………. Company name:……………….................………………Address………………………. ………………………………………………....................…………………………………. Nature of Business………………………................…………………………………….. Telephone/fax/:................................................................email:.......................................... Company’s certificate of incorporation No:……………..............……………………. ………………………………….Date...................................................................................... Name of person authorized to act on behalf of applicant:................................................... Title/designation:…………………………………………………………………............. Address:………………………………………………………………........................………. Telephone/Fax No:…………………………………Email………….............…………….. Cell Phone:………………………………………………………………...............………... Request for confidentiality of information: YES ( ) NO ( ) Reasons:………………………………………………….............……………………….. ………………………………………………………………………................……………. Information concerning the controlled substances: Group of substances:……………………………………............………………………… Country of origin/export:………………………….........…………………………………. Quantity to be imported:………………………......…………………………………….. Port of entry:………………………………….........……………………………………… Mode of transport/intended carrier:…………...………………………………………. Information concerning the supplier: (i) Name of supplier:…………………….....……………….....……………………. (ii) Trade of the supplier:………………………………......…....………………….. (iii) Full address of the supplier:…………………………..........…………………… (iv) Country of origin:………………………………………...........………………… (v) Country from which controlled substance or product is consigned……….. (vi) Holder of the product trade mark:………..........……………………………….. Group Substance Number of Ozone depleting isomers potential 38 39 No. 11 Environment Protection Agency Act, 2008 No. 11 Environment Protection Agency Act, 2008 DECLARATION: I……………………………………………………..of……………………………… hereby declare that the information provided in this application is correct and that I am willing and able to use the controlled substance in compliance with all the relevant laws for the time being in force. Signature……………………...............………………..Date.............................................. FORM B APPLICATION FORM FOR A PERMIT TO EXPORT A CONTROLLED SUBSTANCE Name of applicant:…………………………………………............……………………. Address (business):………………………………………...........………………………. Address (residential):…………………………………............………………………….. Passport no:……………………………………….............………………………………. Company’s name:…………………………………….…………..............………………. Nature of business………………………………………………...........…………….. … Telelephone/fax:…………………………………Email .………………….....……… … Company’s certificate of incorporation No:……………………..........……………….. Name of person authorized to act on behalf of applicant:…….........……………….. Title:……………………………………………………………………................………… Address:…………………………………………………………………................……….. Telephone/Fax No:…………………………………Email………….............…………….. Cell Phone:…………………………………………............……………………………... Request for confidentiality: YES ( ) NO ( ) If yes, give reasons:………………………………….............…………………………….. ………………………………………………………..............……………………………. Information concerning the controlled substances Party to which the controlled substance is being exported:…….………………….. Type of controlled substance:- (tick) Recovered:…………………….. Recycled:……………………… Reclaimed:………………….. Used:………………………… Controlled substance Country of Amount Proposed export (M.T.) date of export DECLARATION: I………………………....………………………of………………………………. hereby declare that the information provided in this application is correct and that I am able to export the controlled substance in compliance with all the relevant laws for the time being in force. Signature……………………………......……...........Date………………………………..