Application form for membership in the
PCBs Elimination Network (PEN)

1.  Personal information

I wish to register as an: Institution Individual person

Institution
First 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: