खान अ ध नयम, 1952 / Mines Act, 1952 हाल का खींचा हुआ पासपोट

साईज फोटो ाफ सामने (ऊपर)

(For office use only) छूट के आधार पर स मता माण प के लए आवेदन प
क ओर अ भय थ का नाम लखा
Dy.No. APPLICATION FORM FOR CERTIFICATE OF COMPETENCY
हो, चपकाएं
ON EXEMPTION BASIS
Date: Affix latest attested photograph
(size-3.5 cm x3.5 cm) with name
of candidate on front side (top)
Signature
here.

F O R M – II
Application form to be filled in by a candidate for obtaining a 2nd Class Manager’s { Coal (R)/ Coal
(UR)/ Metal(R)/Metal(UR)}, Overman (R), Overman (UR), Foreman (R), Foreman(UR), Surveyor
{Coal (R)/ Coal (UR)/Metal(R)/ Metal(UR)} certificate of competency on exemption basis. (Strike
out which are not applicable)

1. Name in full : ………………………………………………………………………….

(in English block
letters)
vkosnd dk uke : ………………………………………………………………………….
( fgUnh esa )
2. Father’s name in : …………………………………………………………………………...
full (in English
block letters)
firk dk uke …………………………………………………………………………..
( fgUnh esa ) :

3. Date of birth : ………………………………………………………………………………

4. Category : SC/ ST/ Others (Strike out which are n ot applicable)

5. Present Postal : ………………………………………………………………………………

Address ……………………………………………………………………………….
……………………………………………………………………………….
………………………………………………………Pin…………………...

6. Permanent Postal : Village : ……………………… Thana :……………………………...

Address: P O : ………………………….. Dist : ……………………………….
State : ………………………… ……………… Pin ……………………….

7. Qualifications : a) Date of Passing/Degree/Diploma: ……………………. …………..

b) No. & Date of Certificate : …………………………………………….
c) Name of Institution from which Qualified: …………………………

8. Gas Testing : a) No.: …………………………………. Date of Issue ………………….

Certificate b) Date of Passing …………………………………………………………

9. First Aid : Type …………….No………………………….Valid upto………………

Certificate

10. No. & Date of : 2nd Class Manager No : …………...……… dated: ……………………
each Certificate
Surveyor No : …………………………...... dated: ……………………..
held under the
Mines Act 1952 Overman/Foreman No : …………………. dated: ……………………..
Sirdar/Mate No : ………………………..… dated: ……………………..
Shot-firer /Blaster No : ………………….… dated: …………… PTO
 11. Training : Period of practical experience gained in different mines with actual
date of commencement/termination.

(I)As P.G.P.T./P.D.P.T. ( Certificate Year Month Days

to be submitted from
Directorate of practical
Training.)
(II) In statutory capacity: (A)As Year Month Days
Shot-firer/Blaster (B) As
Sirdar/Mate
(C) As Overman/Foreman
(D)As Second Class Manager
(II) In non statutory capacity: Year Month Days
A. As Apprentice in Mining
B. As Apprentice in Surveying
C. As Surveyor
D. In Research Work
E. In Teaching
F. In Planning
Total :

12. Mobile Number (10 digits only) : ……………………………………………………

13. E-mail Id : ……………………………………………………………………………….

14. Aadhaar No. : ……………………………………………………………………………….

List of documents to be enclosed:

i. Degree/Diploma in original/Mark sheet in original
ii. Matriculation Certificate in original
iii. Post Graduate/Post Diploma practical Training certificate in prescribed format in
Mining.
iv. Two duly attested passport size Photographs with name written clearly on the front (top) side.
v. Medical certificate of fitness in prescribed format signature of the candidate duly attested by
the medical practitioner.
vi. Character certificate.
vii. Fee of Rs: ………, crossed Indian Postal Order / Bank draft No……………….date………..
[NOTE: For certificates under CMR, only Bank Demand Draft shall be accepted.
Revised Fees for Certificates under CMR, 2017: II CLASS: Rs. 900 /-; SURVEYOR & OVERMAN:
Rs. 600 /-]
viii. Original First Aid Certificate.
ix. Self attested copies of all documents./certificates.
x. Stamped (Rs 70/-) self addressed A-4, size envelope.
xi. Any other documents as deemed necessary in support of the application.

I, solemnly declare that the above statements, information and documents are true.

Date…………… Signature……………………………