boe_app
TRANSCRIPT
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2
P
ART-II
PARTICULARSOFALL
CERTIFICATESSUBMITTED
Numb
erof
the
Certificate
Classof
Certificate
PlaceofIssue
Dateof
Issue
Ifatanytime
suspendedor
ca
ncelled,andifso
statebyWhom
Dat
eof
Suspen
sionor
cance
llation
ReasonsforS
uspensionor
Cance
llation
7
6
5
4
3
2
1
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P
ART-III
L
IST
OF
TESTIMONIALS
ANDS
TATEMENTS
OFS
ERVICE
(TheTestim
onialstobeNumberedSeriallyC
orrespondingtotheNumbersgivenincolumn1below)
Sl.No.
ofthe
Testimo-
nials
Dateof
Testimo-
nials
Nameofthe
person
signingthe
Testimonials
Address
and
Designation
ofFactory
or
workshop
whereemployed
Number,
TypeandHeating
Surfaceof
Boilersworked
on
Capacity
inwhich
employed
Serviceof
Applicant
Periodforwhich
employed
Nottobe
filledinbythe
Applicant
Date
of
Termi-
nation
Dateof
Comme
n-
cemen
t
Years
Months
Days
Initial
of
verifier
Remarks
13
12
11
10
9
8
7
6
5
4
3
2
1
3
TotalServic
e
:
______
Y_____
M_____
D_____
TimeServed
forwhichCertificateareproduced
:
______
Y_____
M_____
D_____
TimeServed
forwhichNoCertificateareproduced
:
______
Y_____
M_____
D_____
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PART IV
DECLARATION TO BE MADE BY THE APPLICANT
I do hereby declare that the statements made in Part I,II and lll of this Form are correct and true to the best of
my knowledge and belief and that the papers enumerated in Part ll 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 statements made in Part III contain a true and correct account of the whole
period of my service without exception, and l make this declaration conscientiously believing the same to be
true.
PART V
(Not to be filled by the applicant)
Dated at ..........................................this................................. day of ............................ 201
Signature & seal
Name :
Designation:
Contact No :
Address :
Signature of the Applicant
Contact No:
Present Address:
Signed in the presence of
Certified that Shri ....................................................................................................has been examined for the
Certificate of Proficiency as Boiler Attendant and that he has PASSED/FAILED in the Examination held during
....................................
Proficiency
Certificate No. : ........................................................ Issued on : ..................................... and duplicate recorded
BOARD OF EXAMINERS :
1. 4.
2. 5.
3. 6.
Issue of Certificate of as First Class / Second Class Boiler Attendant when certified to have passed.
4
SECRETARY CHAIRMAN