FORM - 1A (Prescribed under sub-rule (3) of Rule 2A) Application for grant of certificate of competency to an Institution 1. Name and full address of the Institution : 2. Institution's status (specify whether : Government, autonomous, Co-Operative, Corporate or Private) 3. Purpose for which competency certificate : is sought (specify section (s) of the Act) 4. Whether the institution has been declared : as a competent person under this or any other statute, if so , give details 5. Particulars of persons employed and : possessing qualification and experience SL No Name and Designation Qualifications Experience Sections(s and the rules under which competency is sought for (1) (2) (3) (4) (5) 6. Details of facilities (relevant to item 3 above) : and arrangements made for their maintenance and periodic calibration 7. Any other relevant information : Declaration I _________________ hereby, on behalf of ________________ certify the details furnished above are correct to the best of my knowledge. I undertake to - (i) Maintain the facilities in good working order, calibrated periodically as per manufacturers instruction or as per National Standard: and (ii) To fulfill and abide by all conditions stipulated in the certificate of competency and instruction issued by the Chief Inspector from time to time Place: Signature of Head of the Institution Date: Designation:
