Your Application is received.

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KERALA STATE ELECTRICITY LICENCING BOARD

DEPARTMENT OF ELECTRICAL INSPECTORATE
Application Form

Supervisor Grade B Barcode: 0521490

1. Name of applicant ROHITH S
2. Sex Male 3. Date of Birth 16-10-1996
4. Name of Father VN SASI
VECHOOR HOUSE KOOVAPPALLY P O,
KANJIRAPPALLY KOTTAYAM KERALA
5. Permanent Address
686518, KOOVAPPALLY
Pincode. 686518
VECHOOR HOUSE KOOVAPPALLY P O,
KANJIRAPPALLY KOTTAYAM KERALA
6. Address for Communication
686518, KOOVAPPALLY
Pincode.686518, Mobile: 8075137346
7. Email rohiths673@gmail.com
8. District KOTTAYAM
9. General Qualification Degree
B.Tech in Electrical and Electronics
10. Technical Qualification
Engineering
COLLEGE OF ENGINEERING POONJAR
11. Name and Address of Institution in
POONJAR, KOTTAYAM, COCHIN
which the candidate has studied for
UNIVERSITY OF SCIENCE AND
Technical Qualification
TECHNOLOGY
 Chalan Details
Amount Chalan Number Chalan Date Name of Treasury District
800    KL009288840201920E  29-10-2019  TRIVANDRAM  KOTTAYAM
DECLARATION
     I here by decalre that the particulars stated above are correct to the best of my knowledge, I am
not a holder of Supervisor/Wireman Competency Certificate and Permit issued by the Kerala State
Electricity Licencing Board other than those indicated in above is agree to the Cancellation of my
Permit/Competency Certificate that may issued to me in pursuance of this application in case the
particulars furnished in the application are found incorrect or false terminated. 
  Place: KANJIRAPPALLY KOTTAYAM KERALA
 
686518
  Date: 24-02-2019 (Signature)     
Note:
You are requested to print two copies of this application. One copy should be retained by you.
The other copy should be duly signed by the applicant and forwarded along with the original chalan of
remittance of fee and attested copies of original certificate (to prove the age, technical qualification and
experience) to the following address
      The Secretary,   Kerala State Electricity Licensing Board, Department of Electrical Inspectorate,
       Housing Board Buildings,  Shanthi Nagar,  Thiruvananthapuram 695 001.