REACH Application

REACH Application Form
Person Details
Basic Information Go Back (Click Go Back And Re-enter IEC And Company Name To Edit)
1 Name of the Applicant Firm :
2 Address of the Applicant Firm Line 1 :
3 Address of the Applicant Firm Line 2 :
4 Region of the Applicant Firm :
5 State of the Applicant Firm :
6 City of the Applicant Firm :
7 Postcode of the Applicant Firm :
8 Tel: (with STD Code) :
9 Fax: (with STD Code) :
10 Mobile No :
Other Information
11 E-mail :
12 Name of contact person :
13 Designation of contact person :
14 IEC No. of the firm. :
15 Customer ID (UUID) as per ECHA Invoice :
16 Chemexcil Membership Code :
17 Whether ( LSM/ MSM/ SSM/ MICRO SM) :
18 Status of Membership subscription fees paid for 3 years Receipt No. Date
:
:
:
19 Export House Certificate, if applicable :
Certificate No :
Valid Upto :
20 FOB value of exports during the last 3 financial year Last 1 Year (): Last 2 Year (): Last 3 Year ():
Details
Details of manufacturing license issued by the Licensing Authority (in India) for the substance(to be enclosed )


No. Date Issuing authority


Details of the substances registered by your firm


Sr. No. Substance Name EC No. Submission No.



Details of Registration fees paid by your firm to ECHA


Sr. No. ECHA Regn fees paid in Euro as per ECHA Invoice Exchange Rate as per Bank Transaction copies (Amount in Rs ) LOA Fees as per LR Invoice or Data fees as per Lab invoice Exchange Rate as per Bank Transaction copies (Amount in Rs ) Consultancy charges as per consultant’s invoice Exchange Rate as per Bank Transaction copies (Amount in Rs )
TOTAL

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Summary page


Please verify your information below.

Declaration

I solemnly declare that the particulars given in the above statement are correct. I bound myself and the company accountable and responsible for any incorrect Information given in the above statement and shall immediately refund the amount received on the basis of wrong information provided in the above statement. I certify that the claim is as per the provisions of the MAI guidelines of the Dept of Commerce, MoC&I and the registration charges incurred to us has not been claimed or reimbursed elsewhere. We further certify that our claims are submitted to CHEMEXCIL within 90 days from the date of registration.

Signature :
Name :
Designation :
Company Seal :
Countersigned by MD / CEO of the company :
Name:
Designation :
Company Seal :
Place :
Date :