FORM ‘A° Name, etc. ofthe applicant icate of proficiency as Boiler Operation Engineer Part =1 1, Name (in Ful) 2. Father's Name 3. Nationality 4. Date of birth 5. Place of birth 6. Permanent Address 7. Whether appeared in any previous examination 8. Iso, details of date and place Part - II: PARTICULARS OF ALL CERTIFICATES SUBMITTED Nomberof] Gassof | Pace | Dac] Watanytime | Dateot | Reasonot the | Centieste| of | of | Suspended or _feuspension or] suspension or Certificate issue | issue [eancelled, and iso | cancelation | cancelation sat by wtiom T z a a 3 é 7PART - III : LIST OF TESTIMONIALS AND STATEMENTS OF SERVICE (the tesmonials to be numbered serailly corresponding to the numbers given in column 1 below) Seat [Banat] Raf pan | era Naren Te Capac ‘eames | Vugintine | dengan a | “and heat ik employed Feud tevin | Nutabe tekimonials | facotry or | surface of Service of Appicant| Period forwhiet | ean by ortsop where] oer ce moped | worked on aca] sea | Wea ot] aps |e oma cmc tm Nester a | oe i z Z z 5 z a a Tl Sec Tie Revd for wih crite are pedal Tine Served for wish no erties ar provedPart - IV: DECLARATION TO BE MADE BY THE APPLICANT 1 do-hereby declare thatthe statements made in part I, 1 and I of this Form are cortect and true tothe best of my knowledge and belie and thatthe papers enumerated in Part i and submitted. with this form are true and genuine documents and fuer thet the copies ‘of the documents submitted with this form are true and corect. I further declare that the statements made in Part {1 contain a true and correct account of the whole period of my service with out ‘exception, and I make this declaration conscientiously believing the same to be tue Date at this day of 20 ‘Signed in the presence of Signature ofthe applicant Present Address: _ Signatore Designation =... Note: 1. Every application must be accompanied with he requisite fein dhe manner as may be prescribed by the Government. 2, Fwoeopes ofa recent bust Photograph ofthe applicant (size SOmm x 65mm) must accompany the applcaton with applicants signature ont back-tbereo uly attested by a Gazatted Of- ficer or the candidates employer. 3. Any, person making & fase statement forte purposeof the admision tothe examination ran- ders himself table to prosecution. 4 Incomplete application's sbi be ejected PART-V. (Not tobe filled by the applicant) Centfied tht Shri has bee examined for Cerificate of Proficiency as Boiler Operation Engineer and that ie has pessedsiled in the examination held during (©. Persdnal identification mark on Body. ‘Signature of Board of Examines Issue of Certificate of proficiency as Boiler Operation Engineer When certified to have passed certificate No__issued on, and duplicate recorded. Secretary Board of Examiners