E-Waste Extended Producer Responsibility Authorization Form
Use this form to authorize e-waste EPR compliance handling for your company and specify the products, markets, and authorization scope covered.
Producer and Contact Information
Company / Legal Entity Name
*
Primary Contact Name
*
Business Email Address
*
example@example.com
Business Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
E-Waste EPR Authorization Details
Manufacturer / Brand Name
*
Product Categories Covered
Laptops
Desktops
Monitors
Printers
Mobile Phones
Tablets
Peripherals
Batteries
Other Electronics
Other
Authorization Scope
*
Full Authorization
Limited Authorization
Renewal
Amendment
Other
Compliance Jurisdiction / Market(s) Covered
*
Authorization Start Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Declaration
Declaration Acknowledgement
*
I confirm that the information provided is accurate and complete
I am authorized to submit this request on behalf of the producer/company
Authorized Representative Name
*
Submit Authorization
Should be Empty: