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    Department of Factories and Boilers

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    sebin
    This document is an application form for a Certificate of Proficiency as a Boiler Operation Engineer from the Department of Factories and Boilers in Kerala, India. It requests personal information about the applicant, details of any previous certificates held, a list of references and work experience in boiler operation, and a declaration by the applicant confirming the accuracy of the information provided. Upon completion, examination results and certification would be recorded in Part V which is not filled in by the applicant.

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    Department of Factories and Boilers

    Uploaded by

    sebin
    64 views4 pages
    This document is an application form for a Certificate of Proficiency as a Boiler Operation Engineer from the Department of Factories and Boilers in Kerala, India. It requests personal information about the applicant, details of any previous certificates held, a list of references and work experience in boiler operation, and a declaration by the applicant confirming the accuracy of the information provided. Upon completion, examination results and certification would be recorded in Part V which is not filled in by the applicant.

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    This document is an application form for a Certificate of Proficiency as a Boiler Operation Engineer from the Department of Factories and Boilers in Kerala, India. It requests personal information about the applicant, details of any previous certificates held, a list of references and work experience in boiler operation, and a declaration by the applicant confirming the accuracy of the information provided. Upon completion, examination results and certification would be recorded in Part V which is not filled in by the applicant.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    64 views4 pages

    Department of Factories and Boilers

    Uploaded by

    sebin
    This document is an application form for a Certificate of Proficiency as a Boiler Operation Engineer from the Department of Factories and Boilers in Kerala, India. It requests personal information about the applicant, details of any previous certificates held, a list of references and work experience in boiler operation, and a declaration by the applicant confirming the accuracy of the information provided. Upon completion, examination results and certification would be recorded in Part V which is not filled in by the applicant.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 4

    DEPARTMENT OF FACTORIES AND BOILERS

    GOVERNMENT OF KERALA
    FORM A
    (See rules 26 and 41)

    APPLICATION FOR CERTIFICATE OF PROFICIENCY AS


    BOILER OPERATION ENGINEER
    PART - I

    1.

    Name (in full)

    2.

    Fathers Name

    3.

    Nationality

    4.

    Date of Birth

    5.

    Place of Birth

    6.

    Permanent Address

    7.

    Whether appeared in any previous examination

    8.

    If so, details of date and place

    Photograph

    Page 1/4

    PART II :

    PARTICULARS OF ALL CERTIFICATES SUBMITTED

    Number of the
    Certificate

    Class of
    Certificate

    Place of issue

    Date of issue

    If at any time
    suspended or
    cancelled, and if
    so state by whom

    Date of
    suspension or
    cancellation

    Reasons of
    suspension or
    cancellation

    Page 2/4

    PART III :
    LIST OF TESTIMONIALS AND STATEMENTS OF SERVICE
    (the testimonials to be numbered serially corresponding to the numbers given in column 1 below

    Serial number
    of testimonials

    Date of
    testimonials

    Name of
    person
    signing the
    testimonials

    Address and
    designation of
    factory or
    workshop
    where
    employed

    Number,
    type and
    heating
    surface
    of boilers
    worked
    on

    Capacity
    in which
    employed

    Period for which


    employed

    Service of Applicant

    Date of
    commencement
    7

    Date of
    termination
    8

    Not to be filled in by
    the applicant

    Years

    Months

    Days

    10

    11

    Initial of
    verifier
    12

    Remarks
    13

    Total Service
    Time served for which certificates are produced.
    Time served for which no certificates are produced.
    Page 3/4

    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 make this declaration conscientiously believing the same to be
    true.
    Date at .. this

    day of

    20

    Signature of the applicant


    Present address

    Signed in the presence of

    Signature ..
    Designation .
    Note : 1. Every application must be accompanied with the requisite fee in the manner
    as may be prescribed by the Government.
    2. Two copies of the recent bust photograph of the applicant (Size 50mm x
    65mm) must accompany the application with applicants signature on the
    back-thereof, duly attested by a Gazetted Officer or the candidates employer.
    3. Any, person making a false statement for the purpose of the admission to the
    examination renders himself liable to prosecution.
    4. Incomplete application is liable to be rejected.

    PART V
    (Not to be filled by the applicant)
    Certified that Shri __________________________________ has been examined for
    Certificates of Proficiency as Boiler Operation Engineer and that he has
    passed/failed in the examination held during ______________________
    Issue of Certificate of proficiency as Boiler Operation Engineer when
    certificated to have passed Certificate No. ________________ issued on
    ________________________ and duplicate recorded.

    (Secretary)
    Board of Examiners
    Page 4/4

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