E: info@repakelt.ie or T: 01 4618 600
E: info@repakelt.ie or T: 01 4618 600

Membership Application Form

All fields marked with * are mandatory

1 Company Name and Address

Company Registered Name *

Trading As *

Company Address 1 *

Company Address 2 *

Company Address 3

County *

Eircode

Country *


2 Company Details

Company Registration No *

Vat Registration No *

Telephone No *

Email Address *

Website Address

Local Authority (Of head office) *

Total Number of premises *


Premises 1 information

*Only fill this section if your premise address differs from your main company address.

Premises Name
Premises Address 1
Premises Address 2
Premises Address 3
Premises County
Premises Eircode
Premises Country
Premises Phone
Premises Contact Forename
Premises Contact Surname
Premises Local Authority


3 Contact Information

Main contact Forename

Main contact Surname

Main contact Type *

Main telephone No *

Main email Address *

Main County *

Main Country *

Accounts contact Forename

Accounts contact Surname

Accounts telephone No *

Accounts email Address *


4 Business type

Please tick multiple boxes if appropriate *
 Manufacturer ATF Importer/Wholesaler Vehicle Importer Retail Only Commercial Casings Dealer Waste Collector Re-Treader Waste Facility (ELT) Tyre Equipment Provider Tyre Recycler
Other (Please specify)


5 Importing

Do You Import Tyres? Please tick multiple boxes if appropriate *
 yes no

Other (Please specify)


6 Direct Debit Mandate


Repak ELT will issue invoices 30 days in advance of requesting payment from your bank.

Retail only members will have a single annual payment due for registration. Importers will have quarterly payments due.

Invoices for 2016 membership will be issued in January, with the fee collected from your bank 30 days after that.


By signing this mandate form, you authorise (A) Repak ELT CLG to send instructions to your bank to debit your account and (B) your bank to debit your account in accordance with the instructions from Repak ELT CLG. As part of your rights, you are entitled to a refund from your bank under the terms and conditions of your agreement with your bank. A refund must be claimed within 8 weeks starting from the date on which your account was debited.

Bank Name

Bank Address 1

Bank Address 2

Bank Address 3

Bank Address 4

Debtor's Account name

Debtor’s Bank Identifier Code. - BIC

Debtor’s Account No. - IBAN

Creditor's Name

Creditor's Identifier

Creditor's Address

City

Eircode

Type Of Payment
 Recurring Payment
Signature

Date Of Signature

Note: Your rights regarding the above mandate are explained in a statement that you can obtain from your bank.

I/we hereby make an application to register with Repak ELT and abide by Repak ELT Scheme Rules. I/we certify that the information given in this application is accurate and complete and can be authenticated if necessary

Membership Fees

Manufacturers €70
Producer/Importers €70
All Others €70
Additional Premises/site €50
Importer Fee (This applies to all tyres imported in a given period) This fee is exclusive of Vat €0.10     per Unit