ANNEXURE -VI FORM - A (See rules 28 and 42) Application for Examination for Certificate of Proficiency as Boiler Operation Engineer Division I - Name, etc., of the Applicant 1. Name (in full) : 2. Father's Name : 3. Qualifications : 4. Nationality and Religion : 5. Date of Birth : 6. Place of Birth : 7. Permanent Address : 8. Whether appeared in any previous Examinations : 9. If so, when and where : DIVISION II - Particulars of all certificate submitted 1. Number of the Certificate : 2. Class of Certificate : 3. Where Issued : 4. Date of Issue : 5. If at any time Suspended or Cancelled : 6. Date of Suspension or Cancellation : 7. Cause of Suspension or Cancellation : Note : (1) Every application must be accompanied by a Treasury chalan for Rs.1000/- or such evidence as may be prescribed by the Government showing that the fee for the examination has been paid into the Andhra Pradesh Government Treasury. (2) Two copies of a recent bust photograph of the applicant (size 2*2 ½") must accompany the application with applicant's signature on the back thereof duly attested by a Gazetted officer or the employer. (3) Any person making a false statement for the purpose of admission to the examination renders himself liable to prosecution. (4) Incomplete application are liable to be rejected. DIVISION III - List of testimonials and Statements of Services. (The Testimonials to the numbered serially corresponding to the numbers given in column 1 below) 1. Serial No. of Testimonials : 2. Date of the Testimonials. : 3. Name of person Signing the Testimonials. : 4. Address and Designation of factory or : workshop where employed. 5. Number, type and Heating surface of : Boilers worked on 6. Capacity in which employed : Service of Applicant 7. Date of Commencement : 8. Date of termination time : Employed in this services. 9. Year : 10. Month : 11. Days : (Not to be filled in by the Applicant) 12. Initial of Verifier. 13. Remarks: Total Service Time served for which Certificates are produced. Time served for which no Certificates are produced: Division - IV Declaration to be made by the Applicant. I do hereby declare that the statements made in Divisions 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. Division III and submitted with this form are true and genuine documents and further that the copies of the documents with this form are true and correct. I further declare that the statements made in division II contain a true and correct account of the whole period of my service without exception, and I make this declaration conscientiously believing the same to be true. Dated at this day of 200 Signature of the Applicant Present Address Signed in the presence of Signature _________________________ Designation _______________________ SSA/BOEC
