fe mad aller 31-12-2020)

Appan fom latory Wel Di-)i 0 9 resjois appln Jlun tori ils sh.alt
RAVIKANT PATHAK
UTA fufAya, 1952/ The Mines Act, 1952
Riod R
1N Dy Nu APPLICATION FORM FOR GAS TESTING
d ated CERTIFICATE OF COMPETENCY

Siguature
T ,

(In capital letters as per Matric certificate)

1. HIdc 41 A (Af2i yHUY d 3JHN) Full name of Applicant
RAV KANT PATHA K
Applicant's name in Hindi
2. HTde% a6TITT fdrct /

3. NTUNY AT8 H. JAadhaar card no.

8BG 937|3 8 o23L
4. a r 45 TIT/ Father's Narne

4A. 9
SI/ JLAMIkANTPATHA|K
aT TFT R t Father's name in Hindi
LLL
5.a/Category(v3r7,/sSC | 3ta. Tolsif/ST 3F/ Others
6. arg wATUT Age proof 10th MARKSHEET a (Date) 2 8S 2 o 16
7.
a / aTt aT uftT CBSE DELHI 8. s3 faf (Date of Binth) 6 So|4l2 0o
(Board/ Issuing Authority)
9 d art faágm sau-qa A faRFlame Safety lamp handling Cert. Date O A0l6|2o2
Tech. Institution / V.T.C.
(5) 1 T ATH/ Aolei iATAI d.AzM. Name of the Mine TAWA I MINE
Mine Manager Principal HODI In-charge Area Training Officer (GVTC
() Stra/ issued by (Tick the correct one)
Training Officer (VTC)

THA| Amount
10. ATTTaty zixH FU | fAfA/ Date
Bharatkosh Ref. No.
11. R T NATUJ-T AR
o 6 0 4- 2 o 2
12, a
a A
o H62o 2
(Medical Cert. Date) (Character Cert. Date)

13. tT 14.dunftryAU-47 NO
(Examination Centre)
NAGPUR (Statutory Cert.)

Whether employed or not? (Yes / No) NOJ zta I aTA/ Name of employerL NO
l6. RE Sr4TE7 (REEt H/Total previous attempts (in words):
NO
faaqu Details:
TET fAADate of Examination RiT a/Examination Centre
aTH /SI. No. of attempt

NO ND NO

17. IR T (Mailing Address)

9 N O-M 6 2 |wA RDN o 3 4 N EARsA

DA B AA RGE NE RALSIlo RESoBH A
LVIR P A T |HA |K|HE IRlA, B lE_ILUILPN 4 6 lo 414
Continue..
 Appinatn lorat versiun nalnitlory w.c.1. 01-01-2020 (all previous application tormats sh.ili be invald ater *1-12-200200

18 I t uai (Permanent Address)

VL wAR FOST B A MUR

PS SIH A A |L DIST SI D
STATE MA DH A P RA D ES HL PIN 4-866 H0
19. 7 Hgst /E-mailId

la y 1 TPo Thlak5 41o TTOLg Imla li| o Im

20. taTsT TR Mobile Number

21. PNO I'S.NE

(a) Whether debarred by the Board of Mining Examination in the past?

(b) if yes, debarred till date

| enclose a self-addressed envelope (10cm. x 22 cm in size).

enclose three passport size photographs duly attested by the Manager/Gazetted Officer with official seal.

eloct that all the documents or cetificates submited along with the application and the information provided in the applicetion
are GENUINE #

25. 31g0TBi faavUT (DETAILS OF ENCLOSURES):

(9 Self-Attested copy of Valid Age proof
(i) Original Medical certificate of fitness in prescribed format.
Gi) Original Character certificate in prescribed format.
v) Self-Attested copy of Flame Safety Lamp Handling certificate in
prescribed format.
()Receipt of Application fees paid through Bharatkosh
(vi) An affidavit to the effect that "all the documents or certificates submitted along with the
application and the
informatiorn provided in theapplication GENUINE"# are

(vii) Two duly attested

passport size Photographs with name written clearly on the front
shall be by the Manager of Mine (top) side. Attestation
a Gazetted officer with office
or a

(vii) Self-Attested copy of Aadhaar

seal/stamp.
(x) Self-addressed A-4, size envelope.
RAVIRANT PAT HAk
HedT Yours faithfully,

fais Date.
ATdC EFAT/ Signature of Applicant
# t 3TdaT faT T7777 HFDd HTAT JIVTT | ANY
SHALL BE
APPLICATION WITHOUT THE AFFIDAVIT
SUMMARILY REJECTED.

Note: Incomplete application shall not be accepted.

Complete application with required documents shall be submitted to the concemed
Zonal or
Regional office of DGMS.
 214 Cnral 8oard of
Secanaary Educ ation,
S Nu SSt20 it TLUT Ta+tAau uiem (u 2014 Deihi
16) Registraton No
AË 15/14107.0g2e
sECONUARY
SCH0oL EJAMINATION
13 7M2 Z TaBIa TqTGt e7 Grade (SESS1OH 2014 16)
Sheet c u m Certufcate of
1ut Ti rii 7his 's to Certty thal RAVIKANT PATHAK Pertuemance
HTRol tio 1261812
ktother & stther siGuardiin s 4ame LALITA PATHAK I LAXMIKANT PATHAK
AN ai Date of Birth 0S/04/2001 STH APRIL TWO THQUSAND ONE
17 Schoo 14107-DAV PUBLIC SCHOOL CWS JAYANT SiDHI MP
HUTA ATTA T has perlormed as (oliows
-

:rtnT. i4712a Academie Pertormance Parn-1 Scholastic Areas

Subject Code bnd Hame

101 ENGLISH COM B2 Ci A2 82 B

002 HINDI COURSE-A C1 B2
041 MATHE MATICS A ET A2
B2 A1 C1 82
o86 SCIENCE 07

087 SOCIAL SCIENCE 82* 07 A

C2 B2
C1 81 08

agditora

afr1 az fa n sitTA (FTTANT) Gumulatvo arade Point Average (CGPA)

FUa Nti n TRI.a1
(RR l t * A Grade n Asaesament ol Speakng and A2 x A2
2() rNA ¥ A Lita Skills 4 I Part
tIslerung SAs (hSL)
2:-21 FM &ra Co-Scholaslic Areas
Life SA Class Class 1
Aa Jna Dascnplive Irndicators
Anindependent thinkor. makes decislons, exhibltu problem
sotving kitls under
Grade aAr - Descriplive Indic ators
1eachers guldance d e e 1 periona suengths and wknesses, analyses a problem with
ThinkingShlls i e v a n t iniormauon and usually thoo191 poropriate alfenatlve1 and
B
makes msaninglul decision
mpathetuc. shows 3ensitiviy towards diferenty bled d appreclates otherro
poinls o view, has very goo0 Inierperional anG Empathetic, with go0d interpersonal and communleuton shlHs, v1ually
Social Sills islener and olloctive 1pesker,
communicatlve skIlls, an acUve observes School rules. rsponds appropriatey Takes feedback and uicsm
accepis
feedback posUvely
self-confideni and optimislic. ules to deal with stress In
calm In adverse sltuatlons. sometmes
healthy way remains
a
dentifies weaknesses, strss and negatveomoilons (atriy weu, managos
Emotlonal Skitls does nol expres39s emouon them with self conldence and is empathetic.
ppropriateoly

2 1\8)HN 17120 Wor Edur 3tion

lonovativo wilh excellent grasp of any assigoment, very punctual In the
complelion ol any
a3signed lask, novatve, with eicelient çrasp of any assignment and ls very punctual ln
1elf-motlvated, empathetlc, lnsplres ouhers and
Work Education
CGlte nt 1eam worko, Athe completon of set lash, sell-motivated, mpathetie, Inspres oihers ano
a
|xcelent leam worh r Readlly shoulders respongibilly

2
Cu l *ala
*4 Visual end Pertorming Arts:
2 U:74 t-n Paicpales actively in artistie actrvitlet at dikerant levels, enthusias lCSlly plans
3nd cornducis ciesuve svanis, very observant, displayYs an aesthelic, Innovatuve Partc ipale acinely in c t t i s al ditlerent b v e l s , n i n u s u s t c a l l y
nd
the
P a n s and conducis ere ative a.
approdch to
àppreclatlon and underslanding of dilferpnt hrue,
Pertuinung Ans art forms. InnovatiYe approach lo the
the appreciallon 3nd .uhdorsadingonen
L- approach lo appreciatlon and

|orm
2 (0)\D) ANNGIHal ta j Afiludes Jnd Values
u1 1owards au4TNE 3 9 Descripuve ingiciiors
4 - 4 ] Dcsciplive Indicators
CourtecU: towards tsachers and usually follows the rules Grade rade
Y courto ous Iowards teachers folowi school rues, has a postuve
a t i t u d e and akes crlticism In ihe righi ipirit
Teacthers
Exprossot ldeas and opinions with clarity, Is senslltve towards pears a
Sonsitbve and suppornlve towardi peers and dierentlyabled schoolmates,
differgr.tly 3blod schooimatet, respocts dlversity. and Is receptive lo new ldeas
xpresses ldea1 and opln bns ith clarity In a çroup. rocepihve to new
Schoolmates opinlons and 1ugg0stions, dlsplays sensilIy to ditfsrences

An enthusiastic parnlclpant in varlous school pro9rammes and environmentar

Punctual and lakes part In school
inuatives possusses leadershlp skilis. Usually lakes in pride In the school and programmos ragulary. posseses
leadershlp qualitles and displas leam spirit, motates and insplres others
school
proporty.
Erivironmednt e s &espocis partielpate. Rospects schoof property and takos pride în the school.
nme
Has some understanding of value syslems, Ia honest, respects dversity. displays Understands value srstems qulte well and adheros to school ruios. respects
otaui rozpons Ibilty the natlonal flag and symbols. Honest courteous and senstive to diversity.
with a posluve outlook
Vatue Syslems
HT1 Part 3 H qTUA YTUUGIN Co- Currlcular Activllies
3A) t q i n aATI Co Curricult Activities :

Lney CAre SA7 Regula:ty parlicipajes In Iterary inter znd Intra mural evenls, appreciates
Plans, organizes and actlvey partlc ipates In liter ary and reatve evenls at
written and spoken lterary lorms, oxpreeses ldeas and opinlons creatlively. an various ievels, writos short storios, 1lterary crilclssm
p o 9 s poems,
ayio re2d0 and Inspires olners. an avld reador and displays a hlgh levol ot inlerprelatlve skls.
A
Soere Sa Has good laboratory sklls end particlpates In sclentlnc activities at the school Actlvety particlpates In sclentiflc activitlos at Inter and intra-mural events,
love Plans and coordinates sclence relsted evenis, very obsonvant and has good
aboratory skilla.

3 (J(8) dPA DA 21Nna 17iel Hentth end Ptiyslcal Educolon

Sd o Talentec In an ldontiñod sport and the reprosents school, disclplined, punctual, Talented In an ldantinod sport ropresents school, possesses siamina.
possesse alrongth and tlamina Displayt good toam spirt And is usualy strength, agillty and lexlbilty. damonstrates k hoathy team apirit and is
sclpllned.
Duntlual
d * weidae banontttates Interesl and knowledgo ol types of planis and uso of fertllz ofs, Shows enthuslanm lor pardening/shramdaan tanke asslgned and eady to
voluntoars wor wth hands Has baslc knowledg o ypes ol pldnis, gardenin0 tools
sdy
l , wark with hands brlngs in now Idoas and ehowr
creal lvity &nd the time of the yoar during whleh they are to be planted'gOwn
fo theamdaar 8nd Is able ta Ins pire other

1
1 7 Uryadon itudr taUTT Resun QUAI irD FOR ADMISSION TO HIGHER CLASSES

LICS

4 i Deih Prlnc
faau v med Stamp of i l h o B ) tiC ult2a(n13tions
44i4 Dale0 28-05 70t
cpl t cort!flc ato, ploos0 visl cbse nlc.in and ot Ela tost aPplic at.

iiCanie
 MEDICAL CERTIFICATE OF FITNESSs

I have examined Shri / Kufari / Sht. ..BaVikant...

Son/ Daughter of Shri. Xmi.Kant....athak...
athok ***"**" aged
..
Years, of Village: ..
....20..********" ilkoan.... P.O.

. mux.. P.S... ha.uIaA.. *******************************°**

Dist..Sid.ht... State..A... .. PIN ..486679... and certify that, he

*****

shé is free from deafness, defective vision (including colour vision) or any other
infirmity, mental or physical, likely to interferewith the efficiency of his / het work and
found him/ hef possessing good health.

This certificáte is being given to him /her for the purpose of. . . a s . A n
****
Examinoha....

Signatüre of Candidate

(To be signed in presence of the Medical Officer)

Dr. P.C. Shrivastava

M.B.B.S.
1. ali No. 4, Satna (M.21 Signature of Medical Officer:. N.G.
No.: 2815
ame of Medical Officer: Dr..RShrivastava
M.B.B.5.
Registration No. Umarr, Gali No. 4 Satna (M..)...
Re. No.: 2815

Seal
Dated: H 8)

at least M.B.B.S. Degree and

Note: Medical certificate granted by a qualified medical practitioner holding
shall only be valid. The date of issue of the medical
registered with Medical Council of India,
certificate should be within one year from the date of application.
 CHARACTER CERTIFICATE

Smt.....KAVIKAN.T...ATHAK..
****'***°**

This is to certify that Shri / Kumari /

is known to me for the
Son/ Daughter of Shri ..AMUKANT..ATHAK...
good
Month(s)/Year(s). To the best of my knowledge he /
she bears a
last.
moral chákacter.

to him/ her for the purpose of...AS..ESTING

This certificate is being given
*. AMING.TLO.N... *****°* ***

(Signature with date)

Name of Issuing Authority:..TAMGSHDESPANDE..

I 2 TA, YT9ITET
(Official Seal)
 FLAME SAFETY LAMP HANDLING CERTIFICATE

Date o6]gn
'***"

This is to certify that Shri/ Kuhnari / Sh1t. .BAVIk.a).. PALHA..

Son / Dayghter/ wfe of Shri .AXMAKAN.1.AAk.. ** ******1

working/ studying at . AWA2MNE... Mine 7 TC

..
Technical Institute, is familiar with the construction of flame safety lamp and that in my
opinion he / _hé is able to test for the
presence of inflammable gas.

This certificate is being issued to him her for the purpose of appearing in Gas

Testing Competency Examination under The Mines Act, 1952.

heM

*******'***'******** ***** *

(Signature of Issuing Official*)

LR./INCHARGE
NameHOName of Mine
Name of Issuing Official:GANESH DESPANDE
/ VTC/ Technical Institute:
A W A 2M I N EP K D
TAA-2 MINE
Name of the Company/ Owner (if applicable):
W
Complete Postal Address (with Pincode): PAIHAKHE.RA AREA,

0S/o6l27 DIST BETUL

m T L

State: M.P_Pincode: 460449

(DYfidal seal)

*Issuing Official (Definition) Mine

Manager (for Mines); Area Training Officer (for
Group Vocational Training Centre); Training Officer (Vocational
Training Centre);
Principal/ HOD / In-Charge (for Technical Institute)

Note: Certificate issucd by any oflicial other than those mentioned above shall be invalid.
 bharatkosh.gov.in
Gover nment of India Receipt Portal

RECEIPT
Transaction Ref.No. 0906210001332 Dated: Jun 9 2021 11:10AM

Received from MR. RAVIKANT PATHAK with Transaction Ref.No.

0906210001332
Dated Jun 92021 11:10AM the sum of INR 300 (Three Hundred Only)_
through lnternet based Online payment in the account of
Examination Fee for Mining Competency Examinations,,COMPETENCY
EXAMINATIONFEES FOR GAS TESTING
Disclaimer:- This is a system generated electronic receipt, hence no physical signature
is required for the purpose of authentication
n o n atho

Printed On: 09-06-2021 11:12:12

Courtesy Controller General of Accounts

 Registration and Stamp Depariment
Madhya Pradesh

Certificate of Stamp Duty

Stamp Deails
E-Stamp Code At4) 01014108062021004367
50
SURATiWARAGOV
Total F-Stamp Amount N AND 30
Govt. Stamp Duty (Rs.)AD 50 Municipality Duty (Rs.) 0
Upkar Amount (Rs.)0
JanpadDuty (Rs.) NA 0
Exempted
E-Stamp Type
Amount(Rs.)
Issue Date & Time
0 A)

NON-JUDICIAL
A N ANO 08/06/2021 12:37:25
INOTARY BAL
Service Provider or Issuer Details MAMT BHUMARKAR/SPO10341911201900047
SP/SRO/DRO/HO Details AND BALAJI SUPER BAZAR KE BAJU ME MAIN ROAD BAGDONA GHODA-ÐONGARI
FU
A ON AND BETUL A

Decd Deals
Deed Type ATON AND Afidavit
Deed Instrument GTAHC AMD Affidavit, that is to say, a statement in wniting purporting to be a statement of fact, signed by

it and confirmed by hím on oath or, in the case of persons by law allowed
GISTRAN AND the person making FEGS
F TRA ION AN to affim instead of swearing, by affirmation- Fifty rupees,

Purpose R Affidavit
First Party ieails
Name RAVI KANT PATHAK S/O D/O W/O C/O RAMA KANT
Address B-28 CWs CoLONY INDARA JAYANT,GOPAD BANAS SIDHI SIDHI Madhya Pradesh
INDIA
Number of Persons
SecondPaty Detels
Organization Name WCL PATHAKHERA AREA
Address WCL PATHAKHERA AREA BETUA Madhya Pradesh INDIA
Number of Persons 1

AT
3

AFFIDAVIT
1TRA
AT

SURA TARI
sURAJ TWA *DSTRCT NOTARY*
Reg ia. 14962
DASTRICT NOTARY
Reg No 11982 Vahd t
INO
Valid i loas 25-09-2024
25-09-2024
ANO A
ANO S A 9

Piace My Office
at etut APA
Digitally signed by Mamta
Bhumarkar
Date: 2021.06.08 12:37:27
IST
 NOTARY
Before: The Notary Public at Betul
AstrictBetulM.P
AFFIDAVIT
RAVIKANT PATHAK S/O LAXMIKANT PATHAK aged about 20 years,
by faith HlNDU by occupation STUDENT, resident of: JAYANT COLLIERY,
post JAYANT, Distt: SINGRAULI State: MADHYA PRADESH do hereby
solemnly affirm oath and declare as follows:
1. That, information furnished in my application for GAS TESTING
CERTIFICATE OF COMPETENCY on dated 08/06/2021 and all the
documents and certificates submitted with it are correct and true.

That, in case of any documents/certificates/information is/are found false;

I shall be liable to be punished as per the extant provision of the Mines
Act 1952.

3 That the total number of attempts made by me for the examination

mentioned in Point No. 1 is 0 attempt

4 That, the above statements made by me are true and correct.

5. That, I am swearing thus affidavit before authority.

VERIFICATION
Solemnly affirm before me by that the statement made above are true
Ravikaant Pathak whois and correct, I sign this verification at
duly identified by Advocate
BAGDONA on 08/06/2021 08 20211
SURAJ TIWARI
tant ottab
Name of Advocate (BETUL).
WAR

Signature of Deponent
(Deponent)
Place My Office
at Belui (MP)
Identified by cUFN WA
NOTARY PUBLIC, bagdona distt: betul (Advocate Signature) *
Shown Before Me COn Dt-

AR
Name. A-S/oi ka
wo oe iHentified by
:
DHSRegTSURAJ
RICT NOTARY*TWARI
ed Na. 14962
to
District Notay
Distic: Betui tA.P.
5-99-2024
KAVIKAN T 'ATIA
3iadileN (165)

RAVIKANT PATHAR

RAVIKANT PAIHAT

RAVIKANTPATHAK

RAVIKANT PATHA

RAVIKANT PATHAK

RAVIEANT PATHAK
 Government.of.lndia

Ravi Kant Pathak

Sfo a / Year of Birth: 2001

go/Male

8869 3738 0231

3HTH HTCHT T
HTYGhR
3HTETN

Unique IdentificationAuthorityoftndia
Address: C/O: Rama Kant Sharma, B-28,
C/O: TAT hlrcT RIHT, AT-28, CWS COlony, indara, jayant, Gopad
HT
Banas, Jayant Colliery, Sidhi, Madhya
TYE iT, JYT eovT, FHu,
Pradesh, 486890
HEY HRT, 486890

8869 3738 0231

www
www.uida,gov.in
[email protected]
947
1800 300 1947