SCHEDULE – I
Common application for consent under the
Water (Prevention and Control of Pollution) Act, 1974.
Air (Prevention and Control of Pollution) Act, 1981 and authorization under the
Hazardous Waste (Management, Handling and Transboundary Movement)
Rules; 2008,
No……………………..
Explanatory note for filling in application for
Consent/Authorisation
1.
2.
3.
4.
5.
6.
7.
8.
9.
Any applicant knowingly giving incorrect information or suppressing any
information pertaining to any of the items of the application shall be liable for
punishment as per the provisions under the relevant Act.
The application for shall be submitted in the Office of the Chandigarh Pollution
Control Committee, Madhya Marg, Ground Floor, Sector 19-B, Chandigarh.
The application shall be accompanied by the consent fee in the form of
Demand Draft in favour of the Member Secretary, Chandigarh Pollution
Control Committee. Fee paid is not refundable.
For the items marked strike out which is not relevant.
If any of the items is not relevant to the activity of the applicant, please state
‘Not Applicable’.
If the space for reply provided for any items is inadequate, use additional
sheets, duly referenced.
Item I: Give the name of the person who is authorized by the applicant to
transact their business.
Item 2: Also state the concerned institutions under whose administrative area
the unit falls.
The form shall be accompanied by the relevant documents specified on the last
page of the application form.
Capital Investment – Consent fee is to be paid based on gross fixed capital
investment of the unit without depreciation till the date of application. The
gross capital investment shall include cost of land, building, plant and
machinery without depreciation.
CHANDIGARH POLLUTION CONTROL COMMITTEE
Application form for Consent/Authorization
From
_______________________
_______________________
_______________________
To
The Member Secretary,
Chandigarh Pollution Control Committee,
Chandigarh.
Sir,
I/We hereby apply for *
i)
ii)
iii)
consent to establish/operate/renewal of consent under Section 25 and 26 of
the Water (Prevention and Control of Pollution) Act, 1974, as amended.
consent to establish/operate/renewal of consent under Section 21 of the Air
(Prevention and Control of Pollution) Act, 1981 as amended.
Authorization/renewal of authorization under rule 5 of the Hazardous
Wastes (Management, Handling & Transboundary Movement) Rules, 2008,
in connection with my/our existing/Proposed/ altered/additional
manufacturing/processing activity from the premises as per the details
given below:
Part A: General
1.
Name, designation, office address with :
telephone fax number, e-mail of the
applicant/occupier/industry/institution/
local body.
2.
a) Name and location of the industrial :
unit/ premises for which the application
is made. (Give revenue, Survey
Number/plot number, name of Taulka
and District, also telephone and fax
number.
b) Details of the planning permission :
obtained from the local body/Town and
Country planning authority/metropolitan
Development authority/ designated
authority.
c) Name of the local body under whose :
jurisdiction the unit is located and name
of the license issuing authority.
3.
Names, addresses with telephone and :
fax number of Managing Director/
Managing
Partner
and
officer
responsible for matters Connected with
pollution control and / or Hazardous
waste disposal.
4.
a) Are you registered as a small-scale
:
industrial unit?
b) If yes, give the number and date of :
registration.
5.
Gross capital investment of the unit :
without depreciation till the date of
application (cost of building, land, plant
and machinery).
6.
If the site is located near sea-shore/river :
bank/other water bodies; indicate the
distance and the name of the water
body, if any.
7.
Does
the location satisfy the :
requirements under relevant Central/
State Govt.
Notifications such as
Coastal Regulation Zone, notification on
Ecologically Fragile Area, Industrial
location policy, etc. If so, Give details.
8.
If the site is situated in notified
industrial estate,
a)Whether effluent collection, treatment
and disposal system has been provided
by the authority
b) will the applicant utilize the system,
if provided:
c) if not provided, details of proposed
arrangement:
9.
:
:
:
:
Total plot area, built-up area and area :
available for the use of treated
sewage/trade effluent.
10. Month and
year
of
commissioning of the unit:
proposed :
11. Number of workers and office staff:
:
12. a) Do you have a residential colony :
within the premises in respect of which
the present application is made?
b) If yes, please state population staying :
c) Indicate its location and distance with :
reference to plant site.
13. List of products and by-products :
manufactured in tons/month, kl/month
or
number/month
(Give
figure
corresponding to maximum installed
production capacity)
14. List of raw materials and process :
chemicals with annual consumption
Corresponding
to
above
stated
production Figures, in tons/month or
kl/month or Numbers/month.
15. Description of process of manufacture :
of each of the product showing input,
output, quality and quantity of solid,
liquid and gaseous wastes, if any from
each unit process.
(To be supported by flow sheet and/or
material balance and water balances
sheet)
Part B Waste water aspects
16. Water consumption for different uses :
(m3/day)
(i) Industrial cooling, spraying in mine
pits or boiler feeds.
(ii) Domestic purpose
(iii) Processing whereby water gets
polluted and the pollutants are easily
bio-degradable.
(iv) Processing whereby water gets
polluted and the pollutants are not easily
bio-degradable and are toxic.
(v) Others such as agriculture, gardening
etc. (specify)
Total………
17. Source of water supply.
:
Name of authority granting permission
if applicable and quantity permitted.
18. Quantity of waste water (effluent
generated (m3/day)
i) Domestic
:
ii) Industrial
:
iii) Process
:
iv) Washings
:
:
19. Water budget calculations accounting :
for
difference
between
water
consumption and effluent generated.
20. Present treatment of sewage/canteen :
effluent (Give sizes/capacities of
treatment units):
21. Present treatment of trade effluent (Give :
size/ capacities of treatment units). (A
schematic diagram of the treatment
scheme with inlet/outlet characteristics
of each unit operation/process is to be
provided. Include details of residue
management system (ETP sludges):
22. (a) Are sewage and trade effluent mixed :
together?
(b) If yes, state at which stage-whether
before, intermittently or after treatment.
23. Capacity of treated effluent sump, :
Guard Pond, if any:
24. Mode of disposal of treated effluents, :
with respective quantity, m3/day
i) into stream/river (name of river)
ii) into creek/estuary)
iii)Into sea
iv) Into drain/sewer (owner of sewer)
v) on land for irrigation on owned
land/lease land. Specify cropped area.
(To be supported by Relevant
documents)
vi) Quantity of treated effluent
reused/recycled, m3/day
vii) Provide a location map of disposal
arrangement indicating the outlet (s) for
sampling
v) Boiler Blowdown :
vi) Cooling water
:
blowdown
vii) DM Plant/Softening:
plant washings
:
25. (a) Quality of untreated/treated effluent :
(Specify pH and concentration of SS,
BOD, COD and specific pollutants
relevant to the industry. TDS to be
reported for disposal on land or into
stream/river.
(b) Enclose a copy of the latest report of
analysis from the laboratory approved
by State Board/ Committee/ Central
Board/ Central Government in the
Ministry of Environment and Forests.
For proposed Unit furnish expected
characteristics of the untreated/treated
effluent.
Part C: Air emission aspects
26. Fuel consumption:
Coal
LSHS
Furnace Natural
Oil
gas
Others
(specify)
a) Fuel consumption (TPD/KLD)
b) Caloric value
c) Ash content %
d) Sulphur content %
e) Other (specify)
27 (a)
Details of stack (Process & fuel stacks)
a) Stack number (s)
b) Attach to
c) Capacity
d) Fuel type
e) Fuel quantity (TPD/KLD)
f) Material of construction
g) Shape (round/rectangular)
h) Height, m(above ground level)
i) Diameter/ size in meters
j) Gas quantity, nm3/hr
k) Gas temperature, o C
l) Exit gas velocity, m/sec.
m) Control equipment preceding the stack
(Attach specification including reside
management systems of each of the
control equipment indicating inlet/outlet
concentrations of relevant pollutants).
27 (b)
.
Whether any release of odoriferous
compounds such as mercaptans, phorate
etc. are coming out.
1
2
3
4
:
28. Do you have adequate facility for :
collection of samples of emissions in
the form of port holes, platfor, ladder
etc. as per the Central Board
publication “Emission Regulations
Part-III” (December 1985)
29 Quality of treated flue gas emissions
:
and process emissions.
(Specify concentration of criteria
pollutants and industry/ processspecific pollutants stack-wise. Enclose
a copy of the latest report of analysis
from the approved laboratory by the
State Board/Central Board/ Central
Government in the Ministry of
Environment and Forests. For
proposed units, furnish the expected
characteristic of the emission.
Part D: Hazardous waste aspects
30
(a) Whether the unit is generating :
hazardous waste as defined in the
Hazardous Waste (Management,
Handling and Trans boundary
Movement ) Rules, 2008,
(b) If so, the category No.
31. Authorization required for
i) Collection
ii) Reception
iii)Treatment
iv)Transport
v) Storage
vi)Disposal of the Hazardous Waste
32 Quantity of hazardous waste
generated (kg/day) or (mt/month)
:
:
33. Characteristics of the hazardous waste :
(s) Specify concentration of relevant
pollutants. Enclose a copy of the latest
report of analysis from the laboratory
approved by the State Board/Central
Board/Central Government in the
Ministry of Environment and Forests.
For proposed units furnish expected
characteristics.
34. Mode of storage (intermediate or :
final) (describe area, location and
methodology)
35. Present treatment of hazardous waste, :
if any (give type and capacity of
treatment units).
36. Quantity of hazardous waste disposed :
i) Within the factory
ii) Outside the factory
(Specify location and enclose
copies of agreement)
iii)Through
sale
(Enclose
documentary Proof and copies of
agreement)
iv) Outside State/Union Territory, if
yes Particulars of (i) & (iii) above
v) Other (specify)
Part E: Additional information
37
(a) Do you have any proposal to
upgrade the present system for
treatment
and
disposal
of
effluent/emissions and/or hazardous
waste.
(b) If yes, give the details with timeschedule for the implementation and
approximate expenditure to be
incurred on it.
38. Capital and recurring (O and M)
expenditure on various aspects of
environment protection such as
effluent, emission, hazardous waste,
solid
waste,
tree
plantation,
monitoring, data acquisition etc. (give
figures
separately)
for
items
implemented / to be implemented.
39. To which of the pollution control
equipment separate meters for
recording consumption of electric
energy are installed?
40. Which of the pollution control items
are connected to D.G. Set (captive
powers source) to ensure their running
in the event of normal power failure?
:
:
:
:
:
41. Nature, quantity and method of
disposal of non-hazardous solid waste
generated separately from the process
of manufacture and waste treatment
(Give details of area/ capacity
available in applicant’s land)
42. Hazardous Chemicals – Give details
of chemicals and quantities handled
and stored.
(i) Is the unit a Major Accident
Hazard unit as per MSIHC Rules?
(ii) Is the unit an isolated storage as
defined under the MSIHC Rules.
(iii) Indicate status of compliance of
Rules 5,7,10,11,12, 13 and 18 of the
MSIHC Rules.
(iv) Has approval of site been
obtained
from
the
concerned
authority?
(v) Has the unit prepared on Off-site
Emergency Plan? Is it updated?
(vi) Has information on imports of
chemicals been provided to the
concerned authority?
(vii) Does the unit possess a policy
under the PLI Act.
43. Brief details of tree plantation/green
belt development within applicant’s
premises (in hectares).
44. Information of schemes for waste
minimization, resource recovery and
recycling – implemented and to be
implemented, separately.
45. (a) The applicant shall indicate
whether industry comes under Public
Hearing, if so, the relevant documents
such as EIA, EMP, Risk Analysis etc.
shall be submitted, if so, the relevant
documents enclosed shall be indicated
accordingly.
(b) Any other additional information
that the applicant desires to give.
:
:
:
:
:
46.
I/We further declare that the information furnished above is correct and true to the
best of my/our knowledge.
47.
I/We hereby submit that in case of any change from what is stated in this
application in respect of raw materials, products, process of manufacture and treatment
and/or disposal of effluent, emissions, hazardous wastes etc. in quality and quantity; a
fresh application for consent/authorization shall be made and until the grant of fresh
consent/ authorization no change shall be made.
48.
I/We undertake to furnish any other information within one month of its being
called by the Board/Committee.
49.
I/We agree to submit to the Committee an application for renewal of
consent/authorization in two months in advance before the date of expiry of the
consent/authorization validity period.
50.
I/We enclose herewith a Demand Draft for Rs………………………………..
(Rupees ……………………………………………………………………….…………..)
Drawn in favour of Member Secretary, Chandigarh Pollution Control Committee as the fee
for consent/authorization for a period upto…………….
Yours faithfully
Signature…………..
Name………………
Designation………..
Documents enclosed:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Demand Draft towards consent fee/authorization.
Undertaking or affidavit or statement from Annual Report or certificate from
the Chartered Accountants in support of gross fixed capital investment.
Site plan/location map. (Compulsory for all new applications and for
expansions)
Declaration regarding the distance of the unit from the bank of the main river
or hightide mark of creek/estuary (declared under the Act) and in respect of
stone crusher, for distance from highways and habitations.
Layout plan showing the location of stacks (Chimneys), effluent treatment
plant, effluent disposal areas, pollution control devices, hazardous waste
treatment and disposal areas.
Manufacturing process flow sheet, with descriptive note on the manufacturing
process for each product.
Copies of latest consent/authorization/Environment Impact Assessment
Clearance.
Copy of Small Scale Industries registration certificate, if applicable.
Copies of letter of Intent/industrial license, clearances from the Department or
any other relevant document (please state)
Copies of planning permission certificate issued by the local bodies/District
Town and Country Planning/Metropolitan Development Authorities.
Note : The documents at Sr. No.2 to 10 are necessary for first application. For application
for renewal only document at Sr. No.7 is necessary.
In addition to the above, following documents are also required to be submitted:1. Affidavit of sole proprietorship for proprietorship firm.
2. Partnership deed in case of partnership firm plus authority letter from other partners.
3. Memorandum and article of association of a Private Limited or Limited company plus
specific resolution of the Board of Directors in form of the Authorized Signatory.
4. Feasibility report of the proposed pollution control equipments to be installed like
Effluent Treatment Plant (ETP), Sewage Treatment Plant (STP), Air Pollution Control
Device (APCD) etc.
5. Water Balance diagram showing consumption of water in the various process for each
unit of production.
6. Copy of electricity and water supply bills for the past six months ( in case of renewal of
consent).
7. Details of Chemical reaction.
SCHEDULE – II
Fee in Rupees/Year
FEE STRUCTURE FOR “CONSENT TO OPERATE”
S.No.
Category
Red
Orange
Green
Gross Capital Investment
1
Upto Rs.10 lakhs
1200
900
750
2
Above Rs.10 lacs to Rs.25 lacs
1800
1500
1200
3
4
5
6
Above Rs.25 lacs to Rs.50 lacs
Above Rs.50 lacs to Rs.1 crore
Above Rs.1 crore to Rs.5 crore
Above Rs.5 crore to Rs.10 crore
Above Rs.10 crore to Rs.25
crore
Above Rs.25 crore to Rs.50
crore
Above Rs.50 crore to Rs.100
crore
Above Rs.100 crore to Rs.200
crore
Above Rs.200 crore
3000
6000
12000
24000
2400
4700
9000
14400
1800
3500
7000
11200
48000
28800
22400
72000
47000
35000
88000
70000
60000
180000
120000
88000
235000
180000
120000
7
8
9
10
11
S.No.
1
2
3
4
5
6
7
8
9
10
11
FEE STRUCTURE FOR “CONSENT TO ESTABLISH”
Category
Red
Orange
Gross Capital Investment
Green
Upto Rs.10 lakhs
Above Rs.10 lacs to Rs.25 lacs
1200
1800
900
1500
750
1200
Above Rs.25 lacs to Rs.50 lacs
3000
2400
1800
6000
12000
18000
41000
60000
88000
180000
235000
4700
9000
15000
26000
47000
70000
120000
180000
3500
7000
12000
24000
35000
60000
88000
120000
Above Rs.50 lacs to Rs.1 crore
Above Rs.1 crore to Rs.5 crore
Above Rs.5 crore to Rs.10 crore
Above Rs.10 crore to Rs.25 crore
Above Rs.25 crore to Rs.50 crore
Above Rs.50 crore to Rs.100 crore
Above Rs.100 crore to Rs.200 crore
Above Rs.200 crore
FEE FOR DIESEL GENERATOR SET (DG SET) IN THE SHOPS/SCO’S/SCF’S/BOOTHS ETC.
Size of Diesel Generator set
based on rated capacity
<200 KVA
200-500 KVA
>500 KVA
Consent to Establish
(in Rs./year)
400
500
600
Consent to Operate
(in Rs./year)
500
600
700
[FORM – 1]
[See rules 5(3) and (7)]
Application for Obtaining Authorization for Collection /Reception/Treatment/
Transports/Storage/Disposal of Hazardous Waste*
From: ………………………………………
………………………………………
………………………………………
To
The Member Secretary,
Chandigarh Pollution Control Committee,
Paryavaran Bhawan, Madhya Marg,
Ground Floor, Sector 19-B, Chandigarh.
Sir,
I / We hereby apply for authorization/renewal of authorization under subrule (3) of 5 of the Hazardous Wastes (Management, Handling and
Transboundary Movement) Rules, 2008 for collection/ reception/ treatment/
transport/ storage/ disposal of hazardous wastes.
For Office Use Only
1.
Code No. :
2.
Whether the unit is situated in a critically polluted area as identified by Ministry
of Environment and Forests;
To be filled in by Applicant
3.
(a)
(b)
(c)
Part – A: General
Name and address of the unit and location of activity
Authorization required for (Please tick mark appropriate activity/
Activities:
(i)
collection
(ii)
reception
(iii)
treatment
(iv)
transport
(v)
storage
(vi)
disposal
In case of renewal of authorization previous authorization number and
date:
4.
5.
(a)
(b)
Whether the unit is generating hazardous waste as defined in these
Rules:
If so the type and quantity of wastes(in Tonnes/KL):
(a)
(b)
Total capital invested on the project (in Rupees):
Year of commencement of production:
(c)
Whether the industry works general/ 2 shifts/ round the clock:
6.
(a)
(b)
List and quantum of products and by-products (in Tonnes/KL):
List and quantum of raw material used (in Tonnes/KL):
7.
Furnish a flow diagram of manufacturing process showing input and output in terms
of products, waste generated including for captive power generation and
demineralised water.
8.
Part – B : Hazardous Waste
Hazardous Wastes:
(a)
(b)
(c)
(d)
9.
Type of hazardous wastes generated as defined under these
Rules:
Quantum of hazardous waste generated:
Sources and waste characteristics (Also indicate wastes
amenable to recycling, re-processing and reuse) :
Mode of storage within the plant, method of disposal and
capacity (provide details):
Hazardous Wastes generated as per these Rules from storage of
hazardous chemicals as defined under the Manufacture, Storage and
Import of Hazardous Chemicals Rules, 1989.
Part – C : Treatment, Storage and Disposal Facility
10.
Detailed proposal of the facility (to be attached) to include:
(i)
(ii)
(iii)
(iv)
(v)
(vi)
(vii)
(viii)
(ix)
(x)
(xi)
(xii)
(xiii)
Place :
Date :
Location of site (provide map)
Name of waste processing technology
Details of processing technology
Type and Quantity of waste to be processed per day
Site clearance (from local authority, if any)
Utilization programme for waste processed (Product Utilization)
Method of disposal (details in brief be given)
Quantity of waste to be disposed per day
Nature and composition of waste
Methodology and operational details of landfilling/ incineration
Measures to be taken for prevention and control of environmental
pollution including treatment of leachates
Investment on Project and expected returns
Measures to be taken for safety of workers working in the plant
Signature
: ……………
Designation : ……………
Explanatory note for filling up application for obtaining Consent to Establish/Operate
under Water Act/Air Act & Authorization under Hazardous Waste Rules
Point wise additional points to be mentioned in the explanatory note in addition to the
explanatory note provided earlier
Part-A General:
Point No. 1. Give the name of the person who is authorized by the applicant to transact their business.
In case of proprietorship firm an affidavit to be submitted by the
proprietor and in case of
partnership firm deed of partnership and authority letter from other partners. In case of private
limited company or limited company application has to be accompanied with a copy of
Memorandum & Article of Association. Further, if the application has been signed by any
person other than Managing Director, specific resolution of the Board Directors authorizing
the
person to sign and submit the documents should be attached.
Any applicant knowingly giving incorrect information or suppressing any information
pertaining to any of the items of the application shall be liable for punishment as per the
provisions under the relevant Act.
Point No.2(b) State the concerned institutions under whose administration the unit falls like Estate
Office, CITCO, Municipal Corporation.
Point No. 2(c)
Municipal Corporation U.T. Chandigarh is the local body and issue licenses for
water supply connection, sewerage connection and Fire & safety.
Point No. 5 The application shall be accompanied by the consent fee in the form of Demand Draft in
favor of the Member Secretary, Chandigarh Pollution Control Committee. Fee paid is not
refundable. Consent fee is to be paid based on gross fixed capital investment of the unit
without depreciation till the date of application. The gross capital investment shall include
cost of land, building, plant and machinery without depreciation. Incase building is on rent
or lease then rent deed/lease deed should be attached.
Point No. 8 Industrial Area Phase I & II have been notified as an industrial estate along with IT Park
for IT industries.
Point No. 9 The application should be accompanied with drawings, clearly marked total build up area,
area available with the unit & the area available for the usage of treated effluent/sewage
treatment along with plumbing details and sampling locations.
Point No. 10 For units applying for consent to establish tentative date for the start of the unit should be
clearly mentioned. For unit already in operation the year since which it is functional shall
be mentioned.
Point No. 13
Kindly mention maximum installed production capacity in nos., units etc.
Point No. 14
Process chemicals are the chemical consumed during the manufacturing of the
particular products. This should include raw materials consumption with quantity for
each unit of production and average monthly consumption.
Part B: Waste Water Aspects
Point No. 16. Water may be consumed for being fed into DM Plant/Softner/for cooling of
machinery or for the generation of steam in the boilers.
Sewage is wastewater that is generated from toilets, for hand washings etc.
Trade Effluent is wastewater generated from the industrial processes like
electroplating, pickling, service station etc.
Point No. 17. Water supply source like MC Supply, ground water or tanker etc. should be
clearly specified along with permission from concerned authority if required.
Pont No. 19. Water budget calculations means usage of fresh water in various aspects
like manufacturing, utilities like boiler, DM plant, Softners, gardening,
domestic and generation of waste water/effluent and stream which needs to
be treated .it also includes proposal for reuse/recycle of treated waste water
into the process clearly mentioned on the water balance diagram.
Point No.20&21. Details of sewage/effluent treatment plant along with specifications of
each treatment unit should be submitted. Details of chemical reaction, water
balance sheet & flow sheet for the manufacturing of each product are to be
submitted.
Part C: Air Emission Aspects
Point No. 26: The type and quality of fuel used in Tons/Month should be clearly mentioned
along with characteristics of the fuel like sulphur in case of furnace oil and
ash content in case of wood, coal etc.
Point No. 27: Fuel stacks are the one which are attached to area where fuel is burnt like
wood, High speed Diesel, LDO, Furnace Oil etc. Process Stacks sre the one
which are attached to the process source like electroplating operations where
fumes are to be contained, powder coating etc. The type of Air Pollution
Control Equipment installed like wet scrubber, cyclone, electrostatic
precipitator, bag filter etc. and its details should be clearly mentioned.
Part D: Hazardous waste Aspects.
Point no 30 : Kindly refer to the Annexure for the list of process which generate Hazardous
Waste and the list of category of hazardous waste generated available on the
following website.
http://chandigarhenvis.gov.in/beta/departments/cpcc/hazwaste _rules08.pdf
Point no 34 : The hazardous waste generated is to be stored as per guidelines of
hazardous waste storage issued by Central Pollution Control Board e.g. ETP
sludge is to be stored in properly lined pucca storage area.
Part E: Additional Information
Point No 42. MSIHC Rules (Manufacture, Storage & Import of Hazardous Chemical Rules )
are to be provided.
Kindly refer to annexure for the list of hazardous chemicals as per MSIHC
Rules available on the following website
http://chandigarhenvis.gov.in/beta/departments/cpcc/MSIHC_rules.pdf
PLI is the Public Liability Insurance Act.
Point No. 44. Waste minimization steps taken for reducing the quantity of waste generated
and lesser consumption of chemicals including proposed steps to be taken.
General Information
1.
2.
3.
4.
5.
6.
The application for shall be submitted in the Office of the Chandigarh Pollution
Control Committee, Paryavaran Bhawan, Madhya Marg, Ground Floor,
Sector 19 B, Chandigarh.
For the items marked* strike out which is not relevant.
If any of the items is not relevant to the activity of the applicant, please state
‘Not Applicable’.
Don’t leave any item blank.
If the space for reply provided for any items is inadequate, use additional
sheets, duly referenced.
The form shall be accompanied by the relevant documents specified on the
last page of the application form.