Electrical Appliance EPR Authorization Form

Producer/Importer Company Name

Company Address

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Contact Person Full Name

First NameLast Name

Contact Email Address

example@example.com

Contact Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Authorized EPR Representative/Operator Name

EPR Representative/Operator Email

example@example.com

Appliance Categories Covered by Authorization

Scope of EPR Authorization

Authorization Confirmation (By submitting this form, I confirm that the above EPR representative/operator is authorized to act on behalf of the company for the selected EPR-related activities and appliance categories.)