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(G.C.P.) Ra 2518 (9,000--7-2005

[Spl. S.B.-l6-e FORM 'A' Registration No .

See Rules 26 & 41 of Boiler Operation Engineer 2011 & Rules 26 & 42 of Boiler Attendant's rules, 2011.
THE BOILERS ACT, 1923 (V OF 1923)
Application for Examination of the Certificate of Competency as Boiler Attendant or Boiler Operation Engineer. Application for the endorsement of
validity of a Certificate of the applicant.

Part I:Name,etc. of the applicant -E-- 50mm --7

1 Name in Full (First Surname) :­ Affix 50mm X 65mm size photograph

I
duly signed by candidate.
2 Father's Name (First Surname) :­ (Colour photo with white
background)
3 Nationality :­
65
4 Date of Birth :­ mm

:­

1
5 Place of Birth

6 Permanent Address :­

:- Pin Code: I
I I I I
I
Whether appeared in any previous examination

If so, Details of date & Place

Part IT : Particulars of all Certificates submitted

Place ofIssue If at any time
Number of Class of Date of suspended or Date of suspension
Reasons of suspension or cancellation
Certificate Certificate issue cancelled, and if so or cancellation
(Details of Certificate)
state by whom

PART ill: LIST OF TESTIMONIALS AND STATEMENTS OF SERVICE

(the testimonials to be numbered serially corresponding to the numbers given in column (1) below

Serial Date of Name & designation of Name & Address of factory Number, type and heating
Number of person signing the or Workshop where surface of boilers worked Designation in which employed
testimonials
testimonials testimonials employed on
 -
Service of Applicant Period for which employed Not to be filled by the applicant
Date of Commencement Date of termination Years Months Days Initial of Verifier Remarks
2 3 4 5 n 7

Total Service

Service Period for which certificates are produced "­

Service Period for which no certificates are produced :­

Part IV : DECLARATION TO BE MADE BY THE APPLICANT

I do hereby declare that the statements made in Part 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 Part II and 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 Part III contain a true and
correct account of the whole period of my service without exception, and I made this declaration conscientiously believing the same to
be true.

Dated at this day of 20

Signature of the applicant

Present Address:

LJI[TT
Note:
----------------
Pin Code:
----
1) Every application must be accompanied with the requisite fee. Fees paid in to the Govt.Treasury by E-payment through
www.GRAS.mahakosh.gov.in

2) Two copies of recent bust photograph of the applicant (50mm x 65mm) must accompany the application with applicant's and
signature on the back of one copy.

3) Any, person making a false statement for the purpose of the admission to the examination renders himself1iable to prosecution.
4) Incomplete application is liable to be rejected.

Part V: (Not to be filled by the applicant)

Certified that Soo has been examined for Certificate of Proficiency
as Boiler Operation Engineer/Competancy as a First or Second Class Boiler Attendant and that he has passed/failed in the examination
held during .

Issue of Certificate of Proficiency as Boiler Operation Engineer/Competency as a First or Second Class Boiler Attendant when
certified to have passed.

Personal description of applicant

1) Height: Centi Metres: 2) Marks of Identification:­ 1)

2)

Certificate No.:­ Issued on :­ and duplicate recorded.

Outward No.:­
(Secretary)
Board of Examiners