ECOCARE INFRASTRUCTURE PVT. LTD.
503, Mansarovar Complex, Opp. Laxmi Hospital, Bhimjipura, Old Vadaj, Ahmedabad-380013,
Ph:
email:
APPLICATION FORM FOR MEMBERSHIP
( ALL DETAILS SHOULD BE IN CAPITAL LETTERS )
APPLICANT PROFILE
Name of industry
:
Correspondent Address
Corporate Office
Address 1 :
Address 2 :
Town :
State:
Code :
Contact Person Details
Name: :
Designation :
Tel No. :
Fax No.
E-mail ID :
Web site:
Works
Address 1 :
Address 2 :
Town :
State
Code
Contact Person Details
Name: :
Designation :
Tel No. :
E-mail ID
Name of Consultant/
Reference
:
Fax No.
Web site:
:
Contact Number :
email id
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ECOCARE INFRASTRUCTURE PVT. LTD.
503, Mansarovar Complex, Opp. Laxmi Hospital, Bhimjipura, Old Vadaj, Ahmedabad-380013,
Ph:
email:
APPLICATION FORM FOR MEMBERSHIP
( ALL DETAILS SHOULD BE IN CAPITAL LETTERS )
INDUSTRIES DETAILS
Nature of industry
Constitution of Company :
(Y/N)
:
Cement Plant
Fertilizer Plant
Plastic processing plant
Chemical Plant
Automobiles plant
Mines & Minerals Plant
Steel Plant
Engineering plant
Foundry plant
Pharmaceuticals plant
Asbestos plant
Power Plant
Petrochemicals plant
Ceramic plant
Electroplating
Oil base industries
Bulk drugs
If other specify
Proprietor ship
Public Limited
Private Ltd.
Partnership
Society/ Association/Govt.
Agencies / HUF/ LLP
Small Scale Industries
Scale of Industry : ( Y/N)
SSI Number
Medium Scale Industries
MSI Number
Large Scale Industries
GPCB Details :
Association Details :
LSI Number
Regional Office
GPCB ID
CC & A Number
Valid up to
Association Name :
Membership No:
Valid up to
Name of Major Product
Production ( TPA)
Production Details:
Type of Waste
Category
as per CC&A
Quantity TPA
Storage Capacity at
industries in MT
Waste Description :
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ECOCARE INFRASTRUCTURE PVT. LTD.
503, Mansorovar Complex, Opp. Laxmi Hospital, Bhimjipura, Old Vadaj, Ahmedabad-380013,
Ph:
email:
APPLICATION FORM FOR MEMBERSHIP
( ALL DETAILS SHOULD BE IN CAPITAL LETTERS )
FINANCIAL DETAILS
Mode of Frequency at
ECIPL (Y/N)
:
Daily
Weekly
Monthly
Half Yearly
Yearly
one time
Financial Details :
Amount
DD No:
DD date
Bank Name
Amount
DD No:
DD date
Bank Name
Membership Fees
( Non Refundable)
Sample Testing Fees
Document Attached with application form
1. DD/RTGS slip of Membership Fess.
2. DD/RTGS slip of Sample Testing Fees.
3. Sample Form along with sample (500 gm solid)
4. Membership form with duly filled and sign with seal.
5. State Pollution Control Board certificate ( CTE/CTO)
6. DIC Certificate (SSI/MSI)
7. Manufacturing Process flow diagram.
8. Pan Card Copy
9. List of Director/Proprietor/Partners along with address, contact number, email address on letterpad.
10. Notarized Under taking on 100 Rs. Stamp paper.
I herewith give assurance that above mentioned information is true as per my knowledge & abide to
me if any variation in this information may terminate our membership.
Company Seal & Sign
Name of Authorized signatory
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