(G.c.P.) Ra 2518 (9,0007-2005 [Spl. S.B.lo< FORNI 'A'
Registration No .
See Rules 26 & 41 of Boiler Operation Engineer 2011 &
Rules 26 & 42 of Boiler Attendant's mles, 20 II.
THE BOILERS ACT, 1923 (V OF 1923) / Application for Examination
of the Cenificate of Competency as Boiler Attendant or Boiler
Operation Engineer. Application
ror the endorsement of validity of a Cenificate of the
applicant.
Part II : Particulars of all Certificates submitted
Number of Certificate
Class of Certificate
2
Place of Issue
(Details of Certificate.)
3
Date of Issue
4
If at any time suspended or
cancelled, and if so state by whom
5
Date of suspension or cancellation
6
Reasons of suspensIOn or cancellation
7
PART III: LIST OF TESTIMONIALS AND STATEMENTS OF SERVICE (the
testimonials to be numbered serially corresponding to the numbers
given in column (l) below
Serial Name & designation of Name & Address of factory
Number, type and heating DesignationDate ofNumber of person signing
the or Workshop where surface of boilers worked in which
testimonialstestimonials testimonials employed on employed
2 3 4 5 6
____________
-----
Not to be filled by the applicant Service of Applicant Period
for which employed
RemarksDate of Commencement Date of termination Days Initial of
VerifierYears Months 7I 2 3 4 5 6
Total Service
Service Period for which certificates are produced Service
Period for which no certi ficates are produced
Part IV : DECLARATION TO BE MADE BY THE APPLICANT I do hereby
declare that the statements made in Part I, II and HI of this Form
are correct and true to the best of my
knowledge and belief; and that the papers enumerated in Part n
and submitted with this form are true and genuine documents and
further that the copies of the d0cmnents submitted with this form
are true and correct. ! further declare that the statements made in
Part III contllin 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...
Sign in the presence of a Magistrate or a Government Gazet
20 ted Officer. Signature of the applicant
Signature ,.. Designation with seal or stamp of the
signatory.
Present Address:
P_in_C_o_de_:ITIIIJJ Note: [) EvelY application must be
accompanied with the requisite fee in the manner as may be
prescribed by the Government.
2) Two copies of recent bust photograph of the ap~licant (50mm x
65mm) must accompany the application with applicant's signature on
the back-thereof,duly attested by a Gazetted Officer or the
candidate's employer.
3) Any, person making a false statement for the purpose of the
admission to the examination renders himselfliable to 4) Incomplete
application is liable to be reJected.
Part V : (Not to be filled by the applicant) Certified that Shri
.. has been examined for Certificate of
Proficiency as Bailer Operation El1ginecriCompetancy 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
I) Height: Cenli Metres: 2) Marks ofIdentification:- I) 2)
Certificate No.:- Issued on :- and duplicate recorded. Outward
No.:
(Secretary) Board of Examiners
