GES PT DIVISION

FORMS & FORMATS

Document Name: CONSENT FORM FOR PARTICIPATION IN
PROFICIENCY TESTING SCHEME
Issue
01 Issue Date 01/10/2018 Form No. 03
GES PT DIVISION No.
Rev. No. 01 Rev. Date 19/06/2019 Page Page 1 of 2

Fill the details as per following (handwritten or typed)

Submission of scanned copy of this form through email is acceptable

PT Scheme No.: ________________________________________ Date: ______________
PT Scheme Name: _________________________________________________________________
Lab Code :______________________________________________( will be filled by GES PT Division)

Name of the Laboratory………………………….………………………….…………………………………..

Address: …………………………………………………………………………………………………………

…………………………………………………………………………… Pin code: ………………………….

Telephone: …………………………………….. E-mail: ………………………………………………………

Name of the Contact Person: …………………………………………………….……………………………..

Designation: ……………………………………. E-mail: …………………………………………………….

Telephone: …………………………………… Mobile: ……………………………….………………………

Preferred Courier Agency___________________________________________________

(Please mention the name of more than one courier agencies those have good service network at your door step)

Please tick the following check boxes in acceptance of the statement written ahead:
I/We express our consent to participate in the PT scheme/ PT scheme no., of which is mentioned above.

I/We have read & understood the protocol & convinced with the test parameters & respective test
methods.

All essential apparatus/ chemicals/ equipments & other requirements as specified in the test method, shall
be made available during the test.

I/We understand that my/our participation may be revoked on non-compliance with time schedule as
instructed by PTP.

Our laboratory is accredited as per ISO 17025 in above all/ some test parameters & our certificate Number
is __________________________ which is valid up to_____________________________.

Our laboratory is not accredited as per ISO 17025 in all/ some test parameters, whereas only calibrated
equipments will be used in particular test & calibration status will submitted along with PT results for non-
accredited parameters.

Prepared & Issued By Review & Approved By

PT Coordinator Proprietor
 GES PT DIVISION
FORMS & FORMATS
Document Name: CONSENT FORM FOR PARTICIPATION IN
PROFICIENCY TESTING SCHEME
Issue
01 Issue Date 01/10/2018 Form No. 03
GES PT DIVISION No.
Rev. No. 01 Rev. Date 19/06/2019 Page Page 2 of 2

Participation fee along with GST is enclosed herewith as per following details.

Fee Discount Net Amount GST@18% Total Amount

Payment Details:

Cheque*/DD*/NEFT No._______________________________________ Dated_____________

Drawee Bank_________________________________________________

Organization’s GST No.________________________________________

Date:

Name & Signature______________________________________ Stamp of Lab

(Authorized Signatory)

Bank Account Details for payment:

Account Name: GES PT Division
Bank: HDFC BANK Ltd.
Bank Address: Shop no. 02 to 09, Vardan Complex, 1st Floor, V.I.P. Road, Karelibaug,
Vadodara-390018
Account No. 50200035317543, IFSC: HDFC0000147
PAN: APWPS2464K, GSTIN- 24APWPS2464K1Z5

*Cheque/DD shall be drawn in favour of “GES PT Division “payable at Vadodara.

Email Scanned copy of duly filled consent form to: gesptp@gmail.com

Prepared & Issued By Review & Approved By

PT Coordinator Proprietor