M E M B E R S H I P F O R M

COMPANY NAME :
COMPANY ADDRESS :
_____________________________________________________
NATURE OF BUSINESS : _____________________________________________________

REPRESENTATIVE(S)
1. NAME :
DESIGNATION :
TELEPHONE NO. :
FACSIMILE NO. :
CELLPHONE NO. :
E-MAIL ADDRESS :
2. NAME :
DESIGNATION :
TELEPHONE NO. :
FACSIMILE NO. :
CELLPHONE NO. :
E-MAIL ADDRESS :

SUBMITTED BY : _______

_____________
DATE

Notes: Send this form through e-mail to ymdizon@yahoo.com. Membership Fee is

PhP3,000, valid for one year with 2 official company representatives. A fee of PhP1500, for
every additional representative will be charged. Checks should be made payable to
Environmental Practitioners Association (EPA). You can also deposit payments to Land
Bank of the Philippines, Clark Branch with Current Account Number 1582-1015-11. E-mail
bank deposit slip for confirmation and to secure Official Receipt for payment. For details and
other inquiries, please call the EPA Secretariat through CDC-EPD c/o Engr. Roie Magat, Ms.
Mayflor Candelaria, or Ms. Yasmin Dizon.