ANNEXURE - V Last Date of Submission Registered No. FORM - A Application for First/Second Class Certificate of competency as Boiler Attendant, under Andhra Pradesh Boiler Attendant Rules. Division I - Name, etc. of the applicant: 1. Name in full Affix a recent passport Photograph. 2. Father's Name 3. Nationality 4. Date of Birth 5. Place of Birth 6. Permanent Address 7. Mailing Present Address (Mention Door No. Street, Village , Post, District. And Pin Code) 8. Class of Certificate applied for 9. Challan No. . . . . . . . . . . Date . . . . . . . . . . . . Amount Rs.. . . . . 10. Whether appeared in any previous examinations 11. If so admission Card No., Date and Place of Exam Division II - Statement of Service (The following statement of Services shall be filled by the applicant. Separate SERVICE CERTIFICATE (S) shall be submitted by the applicant issued by his EMPLOYER (S) mentioning clearly the Registry No. of Boiler (s), Type , Heating Surface or Rating, Period or Nature of work performed. The service certificate (s) shall be signed by the Employer, Chief Engineer or in-charge of the plant.) Sl.No . Registr y No. of Boiler Type Heating surface (rating) SERVICE OF APPLICANT Nature of work Performed. Fro m To Time employed In this service Year Month Days Total Service DIVISION - III Particulars of all previous certificates (if any) issued in India Number of Certificate Class of Certificat e Where issued Date of issue If at any time sub period/cancelled if so, state by whom Date Cause of suspension or cancellation 1. 2. 3. 4. 5. 6. 7. 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 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 Division II contain a True and correct account of the whole period of my service with out exception, and I make this declaration consciously believing the same to be true. Date at this day of 200 Signature of the Applicant Division V - Certificate of Compentency Certified that Shri /Mr ________________________________________has been examined for certificate of Competency as Boiler Attendent of __________________ Class on this _________________________day of _____________________2001 and has/has not satisfied us of his fitness to hold a Certificate of Competency as a ________________________________class Boiler Attendant. He has therefore passed/ failed. Signature of Board of Examiners ISSUE OF CERTIFICATE Certificate No.________________________of the ___________________class Boiler Attendant issued and the duplicate recorded. Secretary Board of Examiners
