ENVIRONMENTAL PROTECTION AGENCY (EPA)
P.O. box 4024
302-A Bright’s Building, Old CID Road,Mamba Point6
7
Application Form for Accreditation of Environmental Consultant Firms
Please fill out the application form carefully
Environmental Protection Agency of LiberiaPursuant to Section 10 of the Environmental Protection and Management Law of Liberia (EPML)
Firm Information
Name of Firm
Environmental Firm Name only Register
Business Registration Number
only Number
Date of Incorporation:
-
Month
-
Day
Year
Date
Office Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email Address:
example@example.com
Contact Person:
Environmental Contact Person Only
Contact Person:
Please enter a valid phone number.
EPA-Licensed Environmental Consultants
Consultant 1:
Name of Consultant (1)
Environmental Firm Name only Register
EPA License Number:
Please enter a valid License number.
Certification Date
-
Month
-
Day
Year
Date
EPA-Licensed Environmental Consultants
Name of Consultant (2)
Environmental Firm Name only Register
EPA License Number:
Please enter a valid License number.
Certification Date
-
Month
-
Day
Year
Date
Technical Profile and Experience
Sectors of Expertise:
Sectors Expertise only
Services Offered:
Which type of Services Offered:
Summary of Past Projects (Attach separate sheet if needed):
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of
Affiliation and Proof of Payment
Membership ID or Certificate with UCEL:
Only
Date of Membership:
-
Month
-
Day
Year
Date
Payment Receipt Number:
Payment Date:
-
Month
-
Day
Year
Date
Declaration
I hereby declare that the information provided is true and accurate to the best of my knowledge. I understand that any false or misleading information may result in disqualification or revocation of accreditation.
Name of Authorized Representative:
Only
Signature:
Date
-
Month
-
Day
Year
Date
Apply Now!
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