RESPONSIBLE CARE® – OUR COMMITMENT TO SUSTAINABILITY

Questioner for Potential Member and being New Member of KN-RCI

Commitment on Responsible Care®

A. COMPANY PROFILE

1. Name of Company:

2. - Address:

- Phone, Fax, Email & Website:

3. Year Established:

4. Status*): (a) State owned company (BUMN) (c) Multi National

(b) Local Company (d) Joint Venture

(e) Other: ………………………….

5. Name of President Director / CEO:

6. a. Number of permanent employee:

b. Number of contractor employee:

c. Name of Contact Person / Responsible Care® Coordinator:

d. Contact Person’s Phone, Mobile/HP, E-mail:

B. PRODUCT / SERVICE PROFILE

  1. What products / services do you offer?
  1. Who are specifically the clients for your products / services?
  1. What is the type of industry of your client(s)?

C. ISSUES OF INVOLVEMENT

  1. Has your company been involved in Responsible Care initiative or issues of Environment, Safety and Health? If “YES”, please describe (give example of latest involvement)
  1. Has your company been involved in promoting Responsible Care Program? If “YES” in what, why?
  1. Does your company have a Coordinator of Responsible Care?

D. ISSUES of SUSTAINABILITY

  1. Is your institution being audited regularly?( YES / NO )
  2. Does it post an annual financial report( YES / NO )
  3. What is the source of funding?

E. ISSUES of EXPANSION

  1. Do you have any plan to expand or develop your products / services with another or more specific products / services?

If “YES” what kind of products / services will be expanding or developing?

If “NO” why?

F. ISSUES OF FUTURE PLANNING

  1. Are you looking for some institution or resources to support your activities? ( YES / NO )

If “YES” what kind of support(s) do you need?

If “NO” why?

  1. Has your company done any training, workshop, or seminar programs on industry issues, concerning the ESH (Environment, Safety and Health)?
  1. On average, how many companies or people from the industry participated and which level?

21. Do you have any Hot Issue that industry needs to watch?

22. Do you have any program such as Open Day or Community Day?

23. Any idea about Crisis Emergency Plan in and off your site?

  1. Does your company have a regular outreach (training, workshop, or seminar) program to meet with people from industry?
  1. Structure of Organization (please describe)
  1. Mission and goal statement (please describe)
  1. What do you expect as member of KN-RCI?

28. What do you contribute to support KN-RCI activities?

------, ------

( ______) ( ______)

CEO & President Director CEO / Director

of new member company of company sponsor

*) If the pages are not enough please add new ones.

After filling in and completing all above items, please return to the following address.

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