Climate Cleanup Priority Registration

PRIORITY REGISTRATION FORM

This form is used to advise us that you are interested in registering your details with us so we can know more about you and how we should best respond to you.

Please enter your identity and location details and select category classifications below. Also use this form to modify and update any details previously submitted for update. Time to complete 2 minutes max.

► #1 Contact Person

The contact information below is used only to communicate with you -* Required
Salutation*		`First Name*`
Last Name*		`Position*`
	Enter Your Carbon Pollution Data Below If Available:
Remarks / Enquiry	If applicable include CO2 Emission Data - speed, content, temperature and primary fuel source (coal, oil, gas etc) and annual tonnage in this space below (typing area expands): SPEED: CONTENT: TEMPERATURE: FUEL SOURCE: TONNAGE: COMMENTS:
What I Want*	Tell us what you want & when up to a maximum 128 characters

► #2 Address Details

Please modify as needed: * Required
Organization*
Department		`Building`
Street		`PO Box`
District		`City/Zip`
Country*		`Toll-Free`
Phone*		`Fax`
E-Mail*	Replies to enquiries through this feedback form will be forwarded to this email address. The e-mail itself remains securely protected from spam harvesters.
Internet URL
Activities	Tell us what your main focus is up to maximum 128 characters

► #3 Registration Classifications

Adjust selected categories as appropriate to reflect your organisation´s
fields of activities, pollution source (if applicable), custom license,
marketing rights, territory, investment or Ambasadorial rRole desired or preferred:

Fields of Acitivties

Organizational Type
Multinational Corporation
National Corporation
National Government
Provincial (State) Government
Non-Government Organization (NGO)
Public Company
Private Company
Investment Group
Individual
Student

Custom License Category
Exclusive
Master Exclusive (selling sub-licences)
Non-Exclusive

Territory Requested
Global
Regional
National
Corporate In-house
Government In-house
Government Defense

Ambassador For
The Climate Cleanup Group
Global Ambassador
National Ambassador
Special Envoy
Celebrity Envoy

Comments:
re: Ambassadorial Role
re: Any matter you like

Pollution Source
Carbon (CO2) Source
Electricity Power Plants
Industrial Smoke Stacks
Road Transport
Air Transport
Sea Transport
Defense Forces
Petrochemicals
Oil Well Gas Flaring
Cement
Alumina

Marketing Rights Category
Global Unrestricted
Global Restricted
Regional Unrestricted
Regional Restricted
National Unrestricted
National Restricted

Investment
Investment Fund
Public Company
Private Company
Individual

Sales Agents For
The Climate Cleanup Group
Advice of Introduction
Acknowledgement of introduction
only made if introduction is
notified prior to a third party
contacting us directly via Internet
and agent pre-registered and
accepted by The Climate Cleanup
Group - enter details below: