[kku vf/kfu;e] 1952 @ Mines Act, 1952

xSl ijh{k.k iek.k i= ds fy, vkosnu i=

dsoy dk;kZy; ds
iz;ksx gsrq
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___________

APPLICATION FORM FOR A GAS TESTINGCERTIFICATE

ijh{kk dk uke ____________________________________

Name of Examination _______________________________

frfFk ___________
1.

vkosnd dk iwjk uke (fy[kkoV ds cMs v{kjksa esa) full name of Applicants (In Capital letters)

2.

vkosnd dk uke fgUnh esa / Applicants

in hindi

3.

Jh@Lo0 firk dk uke /Shri/Late/Fathers name

4.

eSfVd / lk{kjrk (SSC/Llt. Cert No.)

5.

Name

frfFk (Date)

cksMZ/tkjhdRrkZ
frfFk
(Board /Issuing Authority)

vf/kdkjh
.

7.

lsOVh crh fuoZgu izek.k i= dh frfFk/Flame Safety Lamp

8.

Hkkjrh; iksLVy vkMZj la[;k

(Indian Postal Order

9.

LokLF; izek.k i=
(Medical Cert. Date) .

11.

ijh{kk dsUnz
(Examination Center)

13.

fiNys vafre ijh{kk dsUnz dk uke

(Name of last Prev. Exam. Centre)

14.

i=kpkj dk uke (Mailing Address)

15.

LFkk;h irk (Permanent Address)

viuk gky dk [khapk

gqvk
ikliksVZ lkt dk
QksVksxzkQ [kku
izca/kd
Ds }kjk
vfHkizekf.kr ;gkWa
fpidk,WaA

(Date Of Birth)
handling Cert. Date

frfFk
(Date)

No.)
frfFk

6. tUe

jDe(Amount)

10. pfj= izek.k i=

frfFk
(Character Cert. Date)
12. oS|kfud
izek.k i=
(Statutory Cert.)
frfFk
(Date)

VILL

PS
STATE
16.

eSusa mijksDr fooj.k dh iqfV esa lHkh izek.k i=ksa]dkxtkrksa dh ewy izfr layXu fd;k gSA
I enclose original copy of all certificate/document in connections with the above details.

17.

eSusa viuk orZeku irk fy[kk gqvk ,d fyQkQk (10 l..eh. X 22 ls.eh. ) Mkd fVdV yxk (#i;s 25/-) layXu fd;k gSA
Hkonh; / Your Faithfully
I enclose a self address envelope (10 cm X 22cm. in size) Stamped (Rs. 25/-).

18.

eSusa rhu ikliksVZ lkt QksVksxzkQ izca/kd ds }kjk vfHkizekf.kr layXu fd;k gSA
I enclose three passport size photograph dully attested by Manager.
eSa lR;fuV ds lkFk ?kksk.kk djrk gWaw fd mfYy[kr lwpuk Bhd Bhd ns jgk gwWaA
I solemly declares that the above statement are true.

eSa izekf.kr djrk gwWa fd mij fn, fooj.k esjh mifLFkfr esa fn, x, gSA

vkosnd dk gLrkP
Signature of Applicant

Izkca/kd ds gLrk{kj ,ao

khy

I certify that the above statement have been made in my presence.

Rkfjd / Date __________________________