Application form for membership in the
PCBs Elimination Network (PEN)
1. Personal information
I wish to register as an: Institution Individual person
InstitutionFirst Name / Title (Mr., Ms., Mrs., Dr.)
Family Name
Job title
Mailing address / Postal code
City / Country
Tel. number / (please include international code) / Mobile number / (please include international code)
Fax number / E-mail address
2. Additional information
Please specify to which category of stakeholders you belong (please choose only one category):
Please e-mail, fax or mail the completed form to:
Secretary of the PEN, Secretariat of the Stockholm Convention
11-13 Chemin des Anémones
CH-1219 Châtelaine, Geneva, Switzerland
Fax: +41 22 917-8098; E-mail:
Application form for membership in the
PCBs Elimination Network (PEN)
Government (ministries, governmental agencies, environmental inspectorates, etc.)
PCBs related service industry (entities offering maintenance, treatment or destruction of PCBs)
Holder of PCBs (private or state enterprises holding contaminated equipment or oils)
International expert (consultants, interested individuals, regional centres)
Intergovernmental Organization
Donor organization
Non-governmental organization
Research institution / academia
Please e-mail, fax or mail the completed form to:
Secretary of the PEN, Secretariat of the Stockholm Convention
11-13 Chemin des Anémones
CH-1219 Châtelaine, Geneva, Switzerland
Fax: +41 22 917-8098; E-mail:
Application form for membership in the
PCBs Elimination Network (PEN)
In the field below, please briefly describe your involvement with PCBs.
I am interested in the following areas pertaining to PCBs (multiple checks possible):
Inventory of PCBs Disposal of PCBs Destruction technologies
Maintenance of PCBs equipment Storage of PCBs equipment Illegal use of PCBs
Transboundary movement PCBs in open applications Other:______
3. Declaration
I hereby declare that I will make determined effort toward achieving environmentally sound management (ESM) of PCBs. I accept that all information provided can be shared publicly.
Date:______Signature:______
Please e-mail, fax or mail the completed form to:
Secretary of the PEN, Secretariat of the Stockholm Convention
11-13 Chemin des Anémones
CH-1219 Châtelaine, Geneva, Switzerland
Fax: +41 22 917-8098; E-mail: