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Representative Appointment form

We . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . representing the employer, for environment health & safety

system, do here by designate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .,

Role & Responsibilities are as under:

1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

4. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

5. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

As designation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ., immediate effect to facilitate establishment and maintenance of Environment health & Safety Management System in accordance with ISO 14001:2004 and OHSAS 18001:2007.He will report to Environment health & safety management system’s Manager on the performance management system, including needs for improvement. He will be responsible for monitoring overall EHS performance. He will report to Manager – Environment health & Safety system on the performance of EHS management system, including needs for improvement.

Environment Health & Safety council as from . . . . . . . . . . . . / . . . . . . . . . . . . to . . . . . . . . . . . . ./ . . . . . . . . . . . . .

For the . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Working location / Area / Section, if specify: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

ACCEPTANCE OF DESIGNATION

I ________________________________ do hereby accept this designation and acknowledge that I understand

requires of this appointment.

______________________ Signature / Date _________________

HOD sign _____________________