..
(G.C.P.) Ra 2518 (9,000--7-2005
FORM 'A'
[Spl. S.B.-l6-e
Registration No
.
See Rules 26 & 41 of Boiler Operation Engineer 2011 & Rules 26 & 42 of Boiler Attendant's rules, 2011.
THE BOILERS ACT, 1923 (V OF 1923)
Application for Examination of the Certificate of Competency as Boiler Attendant or Boiler Operation Engineer. Application for the endorsement of
validity of a Certificate of the applicant.
Part I:Name,etc. of the applicant
1
Name in Full (First Surname)
:­
2
Father's Name (First Surname)
:­
3
Nationality
:­
4
Date of Birth
:­
5
Place of Birth
:­
6
Permanent Address
:­
--7
50mm
-E--
Affix 50mm X 65mm size photograph
duly signed by candidate.
(Colour photo with white
background)
I
65
mm
1
:-
Pin Code:
I
I
I
I
I
I
Whether appeared in any previous examination
If so, Details of date & Place
Part IT : Particulars of all Certificates submitted
Place ofIssue
Number of
Certificate
Class of
Certificate
(Details of Certificate)
Date of
issue
If at any time
suspended or
cancelled, and if so
state by whom
Date of suspension
or cancellation
Reasons of suspension or cancellation
PART ill: LIST OF TESTIMONIALS AND STATEMENTS OF SERVICE
(the testimonials to be numbered serially corresponding to the numbers given in column (1) below
Date of
Serial
Number of
testimonials
testimonials
Name & designation of
person signing the
testimonials
Name & Address of factory
or Workshop where
employed
Number, type and heating
surface of boilers worked
on
Designation in which employed
Service of Applicant
Date of Commencement
Not to be filled by the applicant
Period for which employed
Date of termination
Years
Months
Days
Initial of Verifier
Remarks
2
3
4
5
n
7
Total Service
Service Period for which certificates are produced
"­
Service Period for which no certificates are produced
:­
Part IV : DECLARATION TO BE MADE BY THE APPLICANT
I do hereby declare that the statements made in Part I, II and III of this Form are correct and true to the best of my knowledge and
belief; and that the papers enumerated in Part II and submitted with this form are true and genuine documents and further that the copies
of the documents submitted with this form are true and correct. I further declare that the statements made in Part III contain a true and
correct account of the whole period of my service without exception, and I made this declaration conscientiously believing the same to
be true.
Dated at
this
day of
20
Signature of the applicant
Present Address:
Pin Code:
LJI[TT
----------------
Note:
----
1) Every application must be accompanied with the requisite fee. Fees paid in to the Govt.Treasury by E-payment through
www.GRAS.mahakosh.gov.in
2)
Two copies of recent bust photograph of the applicant (50mm x 65mm) must accompany the application with applicant's and
signature on the back of one copy.
3)
Any, person making a false statement for the purpose of the admission to the examination renders himself1iable to prosecution.
4)
Incomplete application is liable to be rejected.
Part V: (Not to be filled by the applicant)
Certified that Soo
has been examined for Certificate of Proficiency
as Boiler Operation Engineer/Competancy as a First or Second Class Boiler Attendant and that he has passed/failed in the examination
held during
.
Issue of Certificate of Proficiency as Boiler Operation Engineer/Competency as a First or Second Class Boiler Attendant when
certified to have passed.
Personal description of applicant
1) Height:
Centi Metres:
2) Marks of Identification:­
1)
2)
Certificate No.:­
Issued on :­
and duplicate recorded.
Outward No.:­
(Secretary)
Board of Examiners