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
Last modified: Thursday, 3 February 2011, 9:22 AM