1.

Address

Particulars of Application

i)         Name of the Institution

     (In block letter & in Full)

:

ii)       Name of the Institution

Address

:

Tele No.

:

Fax No.

:

Telex No.

:

2.

Activity for which authorization is sought

i)         General

:

ii)       Collection

:

iii)    Reception

:

iv)     Storage

:

v)       Transportation

:

vi)     Treatment

:

vii)  Disposal

:

viii)         Any other form of handling

:

3.

Please state whether applying for fresh authorization or for renewal

(In case of renewal previous authorization-number and date)

:

4.

i)         Address of the institution handling bio-medical wastes.

:

ii)       Address of the place of the treatment facility

:

iii)    Address of the place of disposal of the waste

:

5.

i)         Mode of transportation (any) of bio-medical waste

:

ii)       Mode(s) of treatment

:

6.

Brief description of method of treatment and disposal

(attach details)

:

7.

i)         Category (see Schedule I) of waste to be handled

:

ii)       Quantity of waste (category-wise) to be handled per month

:

8.

Declaration: