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 5 pe eimen-eop p of Ex pe_rlenee ( er_tifiqate

GOVERNMENTOF INDIA
MINISTRY OF LABOUR AND EMPLOYMENT
DIRECTORATE GENERAL OF MINES SAFETY

Certificate of *the Coal Mines Regulations,

Regulation s, 'tg6t.
Competency under t957lzo17 | * the Metalliferous Mines

being the *Manager / Owner

of
) tt,tine

belonging to
do hereby certify that
Shri/ Kumari/ Smt. *Son
i Daughter i Wife o{
Shri (whose signature is appended), worked in the above mine

from - to During *his/her term of aforesaid work, *he / she has

obtained practical experience as detailed overleaf. The duties connected
with *hisiher work have involved *hisiher continuous
attendance at the mine and have been efficiently performed by *him/her.

I believe *him/her to be of good character, fit and proper person

for grant of certificate of competency.

(Signature of Manager / Owner with date and office seal)

Manager's Certificate No.
Name of Mine:
Name of Company / Owner:
Post Office:
District:

State:

Pin:

(Signature of Candidate)

Note:
*Delete whichever
is not applicable
#(State Name of Mineral)
 \l Particulars of Place of experience Below ground / Period of Practical Total exoerience
No. practical experience Open-cast / Above ground experience
(a) (b) (c)
From To Years Months Days

Grand Total

During the above period In below ground In open-cast ln all

workings workings
(d) Average Monthly
Output (FOR COAL MINE)
(e) Average Daily Employment
(FOR METAL MrNE)

(Signature of Candidate) (Signature of Manager / Owner with date and office seal)

Name of Mine:

lnstructions: -

(a) (i) Non statutory capacity like general mining / supporting / drilling / blasting / depillaring etc.
(ii) Statutory capacity as a Mining Sirdar / Mate / Overman / Foreman / Assistant Manager etc.
(b) State whether above ground or open-cast or below ground working.
(c) State specially the period spent by the applicant in different mining operation, or surveying operation as the case may
be, if the employment has not been such as to involve continuous attendance of the applicant at the mine, whether under
ground or above ground or open-cast and in what capacity.

Note: Experience certificates, not issued by or not having the official seal of the Mine Manager / Owner of the mine, shall not
be valid.
*For Coal Mine - Experience certificate of Coal Mines with Average&o,nthly Output less than roooT/month or loooom3 / month shall not
be valid.
*For Metal Mine - Experience certificate of mine with AveEg-e Darlylmplo+msnt less than 6o persons (for below ground mine) or t6o
persons (for open-cast mine) or r6o persons (ln All) shall not be valid. However, in case of open-
cast mine with less manpower, experience may be considered valid if copy of Heavy Earth Moving Machinery under Regulation ro6 of the
MMR, 196i is submitted which is valid forthe period of experience,
i
9
il
ti
?
.
 (Annexure - B)

WALK.IN INTERVIEW TO THE POST OF:

Spacefor recent
passport size
To, photograph. Full
name of the
Chief Engineer/Fuel,
candidate should
PSPCL, htiala -14,Zoo1 be mentioned on

(Mine Team camped at the photograph.

Pakur)

FULL NAME: (tn Block Letters)

(b) Present:

DATE OF BIRTH:
(Attach self-attested copy of 't-l
tt
appropriate certif icate) (Put'o' before any single digit viz. o5io7lXXXX)

Age as on 01.o3.2o24 month(s) _day(s)

Board / University Year of Passing

EDUCATIONAL&
PROFESSTONAL QUALT FtCATtON:

(Attach self-attested copy of

appropriate certif icate)
 sr(*sw-*rr-:?r.a:27l@, I9ttbtfBeffif*fffi*+*ilfl}l:::::1

a) General
CATEGORY:
(Put / mark) b) Scheduled Caste (SC).
07. (Attach self-attested copy of
Certificates in support of SC / ST / c) Scheduled Tribe (ST).
oBc)
d) Other Backward Caste (OBC).

Person with Disability (PWD):

o8.
(Put r' mark)
Yes I No (lf Yes the % of disabilitY)
DATE OF ACqUIRING 1'' / 2"" CLASS
MANAGER'S CERTI FICATE OF
o9.
COMPETENCY UNDER THE CMR,
lgsl lzorT (if appl icable)
10. GENDER:

't1. NATIONALITY:

Read: -

1l LANCUAGES KNOWN: Write: -

Speaki
tt. E-MAILADDRESS:

1A MOBILE NO. / CONTACT NO.:

Designation Organization From /To Job description

EXPERIENCE:
(Starting with the current
Designation / Organization)
r)

(May mention designation wise

experience separately in details)

I hereby declare that all statements made in this application are true, complete and correct to the best of my knowledge and
belief. I understand that in the event of any information being found false or incorrect at any stage my candidature is liable to be
cancelled.
Date:
(Signature of the Candidate)
* for examinations wherein Grade Points / Grades are assigned, convert to nearest Percentage of marks.** may attach extra
sheets if reouired.

11

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