Medicine Section

FORM I (refer rule 8)

APPLICATION FOR AUTHORISATION (To be submitted in duplicate)

To
The Prescribed Authority
(Name of the State Govt/UT Administration)
Address.

1. Particulars of Applicant
• Name of the Applicant
  (In block letters & in full)
• Name of the Institution:
• Address:
• Tele No., Fax No. Telex No.
2. Activity for which authorisation is sought:
• Generation
• Collection
• Reception
• Storage
• Transportation
• Treatment
• Disposal
• Any other form of handling
3. Please state whether applying for resh authorisation or for renewal:
   (In case of renewal previous authorisation-number and date)
• Address of the institution handling bio-medical wastes:
• Address of the place of the treatment facility:
• Address of the place of disposal of the waste:
• Mode of transportation (in any) of bio-medical waste:
• Mode(s) of treatment:
6. Brief description of method of treatment and disposal (attach details):
• Category (see Schedule 1) of waste to be handled
• Quantity of waste (category-wise) to be handled per month
8. Declaration
   
   I do hereby declare that the statements made and information given above are true to the best of my knowledge and belief and that I have not concealed any information.
   
   I do also hereby undertake to provide any further information sought by the prescribed authority in relation to these rules and to fulfill any conditions stipulated by the prescribed authority.
   
   Date : Signature of the Applicant
   Place : Designation of the Applicant