ULHASNAGAR MUNICIPAL CORPORATION CITIZEN FACILITATION CENTRE SUBJECT:- LICENSES FOR PLUMBER Token Number (For Office Use) Date:- / / (If Citizen Identification Number is given, do not fill below Details) Applicant's Details: Last Name/ Surname Name Father/Husband's Name Address: Head Information House/Building/Soc. Name: Flat/Block/Barrack No.: Wing/Floor: Road/Street/Lane: Area/Locality/Town/City: Taluka: Pin code: Ward Committee No.: 1 [ ] 2 [ ] 3 [ ] 4 [ ] Electrol Panel No.: Telephone No. (if any): Contact Person: Email Address (if any): Necessary Particulars about above service: Head Information 1 Details of Educational Qualification (Please Tick [?] as applicable) [ ] I.T.I. exam passed [ ] Plumbering course completed under Nehru Rojgar Yojana/ Suvarna Jayanti Rojgar Yojana, UMC Date Month Year 2 Date of Birth 3 Recognized Industrial Institute Name & Address 4 Year of Requisite Educational Qualification Date Month Year 5 Work Experience Citizen Identification Number 6 Details of Educational Qualification (SSC & onward) Sr. No. Educational Qualification Year of Passing Name of Institute / Board Percentage of Marks 1 2 3 4 5 Necessary Enclosures related to above application are enclosed as under. (Please tick [ ? ] for YES or tick [?] for NO) Enclosures Yes/No 1 Certificate of plumber course completed from ITI or under schemes of UMC [ ] 2 Copy of Profession Tax registration certificate (if any) [ ] 3 Photo of applicant (One Copy, Write full name on backside of photo with pen) [ ] 4 Certificates of Educational Qualification (SSC & onward) [ ] 5 Experience Certificates (if any) [ ] 6 Proof of Residence in UMC area [ ] 7 Up-to-date receipt of Tax bill paid [ ] Declaration I/We................................................................................................. state on solemn affirmation that the above information is true and correct to the best of my/our knowledge. If the information given is found wrong then I/We shall be held legally liable for its consequences. Date:- Applicant's Signature ( ) The document may please be delivered to: 1. Self/Nominated Person [ ] a) C.F.C. [ ] b) Camp No. [ ] Name of Nominated Person (________________________________________________) 2. By Post a) U.P.C. [ ] b) Register A.D. [ ] 3. Currier [ ] (Not to be filled if address is same as above) Correspondence Address:- Last Name/ Surname Name Father/Husband's Name House/Building/Soc. Name: Flat/Block/Barrack No.: Wing/Floor: Road/Street/Lane: Area/Locality/Town/City: Taluka: Pin code: Email Address (if any):
