Distillieries - Environmental Clearance

1 Name (in block letters)2 Address for communication3 Age & Date of Birth(Shall be less than 67 years for the membersand 72 years for the Chairman)4 Area of Expertise (As perAppendix VI)Professional Qualifications(As per Appendix VI)5Qualification(s) University Year ofpassingPercentage ofmarks6 Work experience(High light relevant experienceas per Appendix VI)PositionYears of associationFrom to Period inyearsNature of work. Ifrequired, attachseparate sheetsServing Central / State Government Office? Yes/NoEngaged in industry or their associations? Yes/No7Present position and nature ofAssociated with environmental activism? Yes/NojobIf no is the answer for above three, pleasespecify the present position and name of theorganization8Whether experienced in theprocess of prior environmentalclearance?Yes/No.If yes, please specify the experience in a separate sheet (Please restrict to500 words)9Yes/ NoWhether any out-standingIf yes, please provide details in a separate sheet (Please restrict to 500expertise has been acquired?words).10 Any other relevant information? May like to attach separate sheets (Research projects, consultancy projects,publications, memberships in associations, trainings undergone,international exposure cum experience etc.)The Government of……………………is pleased to forward the Nomination of Dr./Sh.…………………...…. for the position of Chairperson / Member / Secretary of the SEIAA / SEAC / EACto the Ministry of Environment & Forests, the Government of India for the Notification.(Authorized Signature with Seal)