Annex 2

Region of Registration : ________

Contact Person Position

SEC Registration #:

Registration No.

Name of Project Date

Position in Firm/Company Date

Remarks : __________________________________________________________________________

Noted By:

Date

REGISTRATION FORM FOR EIA CONSULTING FIRMS

I.General Information

E-mail Address

Business Address to be published

at Website/DirectoryTelephone

No.

Fax No.

Name of Firm

Date of Establishment

For EMB use only

III. List of EIA Reports Prepared (Specify report type)

I confirm that the information provided are true and correct

I understand that all the details provided are subject for verification

Signature & Printed Name

Names

Registration Number

II. List of Registered EIA Practitioners

Area of Expertise