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PART IV
DECLARATION TO BE MADE BY THE APPLICANT
I do hereby declare that the statements made in Part I,II and
lll of this Form are correct and true to the best of
my knowledge and belief and that the papers enumerated in Part
ll 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 statements made in Part III
contain a true and correct account of the whole
period of my service without exception, and l make this
declaration conscientiously believing the same to be
true.
PART V
(Not to be filled by the applicant)
Dated at
..........................................this.................................
day of ............................ 201
Signature & seal
Name :
Designation:
Contact No :
Address :
Signature of the Applicant
Contact No:
Present Address:
Signed in the presence of
Certified that Shri
....................................................................................................has
been examined for the
Certificate of Proficiency as Boiler Attendant and that he has
PASSED/FAILED in the Examination held during
....................................
Proficiency
Certificate No. :
........................................................ Issued on
: ..................................... and duplicate recorded
BOARD OF EXAMINERS :
1. 4.
2. 5.
3. 6.
Issue of Certificate of as First Class / Second Class Boiler
Attendant when certified to have passed.
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SECRETARY CHAIRMAN
