FORM 'D' FORM OF APPLICATION FOR WELDERS TEST (See Rule 49) Sir, I beg to apply for test as a qualified Welder and furnish the details as below. The testimonials of my experience supported by my employer together with one copy of each are sent herewith. 2. Two copies of my photograph in passport size are enclosed. Yours faithfully, (1) Full name of applicant (in block letters) : (Applicant) (2) Age of applicant : (3) Nationality : (4) Permanent address : (5) Details of applicant's service as welder (Full details together with exact periods for which the candidate was employed and capacity in which employed must be given. Each such statement must be supported by applicant's employer or employers) : (6) Details of previous tests at which candidate has appeared and failed (Candidate must state name of Testing Authority before whom he appeared and on which count he was declared failed) : I desire to be tested in the Electric Arc/Oxy - acetylene process of Welding. Date: (Signature of applicant) Forwarded to ................................................................................................................................. ..............................................................................for favour of subjecting Shri ...................................... the applicant to the prescribed Test and communicating the same to the undersigned. The applicant may be informed of the date and place of Test directly at the address mentioned under copy to the undersigned. Chief Inspector of Boilers, Kerala State. 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 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 without exception, and I make this declaration conscientiously believing the same to be true. Date at this day of 200 Signature of the Applicant Present address ........................................................... ........................................................... ........................................................... Signed in the presence of Signature ...................................... Designation ..................................... Note: (1) Every application must be accompanied by a Treasury chalan or such evidence as may be prescribed by the State Government showing that the fee for the examination has been paid. (2) Two copies of a recent bust photograph of the applicant (size 2'' x 2 d'') be accompained with the application with applicant's signature on the back thereof. (3) Any person making false statement for the purpose of admission to the examination renders himself liable to prosecution. (4) Incomplete applications are liable to be rejected. Page No: 4 DIVISION III -Declaration to be made by the Applicant I do hereby declare that the statements made in Divisions I, II and IV of this form are correct and true to the best of my knowledge and belief, and that the papers enumerated in Division IV and submitted with this form are true and genuine documents and further that copies of the documents submitted with this form are true and correct. I further declare that the statements made in Division IV 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. Date at this day of 200....... Signed in the presence of Signature ...................................... Designation ..................................... Signature of the Applicant Present address ........................................................... ........................................................... ........................................................... Note: (1) Every application must be accompanied by a Treasury chalan or such evidence as may be prescribed by the State Government showing that the fee for the examination has been paid. (2) Two copies of a recent bust photograph of the applicant (size 2'' x 2 d'') be accompained with the application with applicant's signature on the back thereof. (3) Any person making false statement for the purpose of admission to the examination renders himself liable to prosecution. (4) Incomplete applications are liable to be rejected. Page No: 3 DIVISION V -Certificate of Competency Certified that Sri ......................................................................................................... has been examined for a certificate of competency as Boiler Attendant of ............................... Class at this .................... day of ........................ 200 .... and has/has not satified us of his fitnes to hold a certificate of competency as a ........................................ Class Boiler Attendant. He has therefore passed/ failed. PERSONAL DESCRIPTION OF APPLICANT 1. Nationality .............................................................................. 2. Religion .................................................................................. 3. Height............................ft ..............................in...................... 4. Complexion ........................................................................... 5. Colour of hair ......................................................................... 6. Colour of eyes ....................................................................... 7. Personal mark or particulars ................................................ Signature of Board of Examiners ISSUE OF CERTIFICATE Certificate No ......................................................... of the ................................................... Class Boiler Attendant issued and the duplicate recorded. Secretary Board of Examiners. Page No: 5
