ANNEXURE - VIII PUBLIC WORKS DEPARTMENT/ WATER RESOURCES DEPARTMENT APPLICATION FOR RENEWAL OF ENLISTMENT (The applicant should study the Rules of enlistment and the list of documents to be annexed with the application from before filling the form. Applications found deficient in any respect are liable to be rejected without any further correspondence.) CLASS ....... CATEGORY .......... 1. Name of applicant Shri/Mr./Mrs. ..................... 2. Nationality Indian ...... .. Other....... ..... 3. Address Regd. Office ............................ ............................ ............................ Head Office ............................ ............................ ............................ ............................ 4. Telephone Number .......... Fax No. ............ 5. Constitution Individual ....... Sole proprietorship concern.... . Partnership Firm.... .. Public Ltd. Company....... Private Ltd. Company .................. 6. If partnership firm, names of the partners/ if company name of Directors 1. ................. 2. ................ . 3. ................ . 4. ................ . 5. ................ . 6. ................ . 7. (a) Name of person holding power of attorney (b) Nationality Indian ..... .. Other ... . 10. Full time technical staff in applicant's employ: (a) to (e) for Civil and Electrical, (f) for Furniture. (a) Graduate Engineers with minimum 5 years of experience Nos...... (b) Graduate Engineers with minimum 3 years of experience Nos...... (excluding a above) (c) Graduate Engineers with minimum 3 years of experience Nos...... (excluding (a) and (b) above) (d) Graduate Engineers with minimum 3 years of experience Nos...... (e) Graduate Engineers with minimum 3 years of experience Nos...... (f) Furniture/Furnishing Designers Nos...... 11. Does the applicant have sufficient T&P Machinery, Equipment and workshop as per requirements mentioned In the Enlistment Rules for the class and category applied for (Attach details on a separate sheet) Yes... .. No... 12. Does the applicant possess valid Electrical Licence(For Electrical ) Yes ... . No... . 13. (a) Details of enlistment with PWD/ WRD (i) Enlistment No. and Date ................. (ii) Date of Validity ................. 14. Is any person working with the applicant is a near relative of the officer/official of Goa PWD/WRD (see Rule 19 of the Enlistment Rules) If answer to above is Yes, give details. Yes ... No.. .. 15. Details of work completed and in progress( which were secured during the last 5 years) (to be filled in porforma as given in the Annexure-III). This list include all works done whose gross amount of work done is more than the required magnitude for the class in which registration is required. 16. Certificates: (i) I/We (including all partners) certify that I/We have read the Rules of Enlistment of Contractors in Goa PWD/WRD as amended up to-date and shall abide by them. (iv) (a) I certify that I did not retire as an Engineer of Gazetted or as any Gazetted Officer employed on Engineering or Administrative duties in any Engineering Department of the Government of Goa during the last two years. I also certify that I have neither such a person under my employment nor shall I employ any such person within two years of his retirement except with the prior permission of the Government. (For individuals seeking enlistment in their own name). (strike out which ever is not applicable). Signature(s) of applicant(s) Name Signature Address 1. ........... ............. 2. ........... ............. 3. ........... ............. 4. ........... ............. 5. ........... ............. 6. ........... ............. Date: No. of documents attached ......... ..
