(For office use only)

Dy.No.
खान अ ध नयम, 1952 / Mines Act, 1952 हाल का खींचा हुआ अ भ मा णत
पासपोट साईज फोटो ाफ सामने
छूट के आधार पर स मता माण प के लए आवेदन प
Date: (ऊपर) क ओर अ यथ का नाम
APPLICATION FORM FOR CERTIFICATE OF COMPETENCY
लखा हो, चपकाएं
ON EXEMPTION BASIS
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 whichever is 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. M a ilin g : ………………………………………………………………………………
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 …………………………………………………………
(If applicable)

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

Certificate
PTO
10. No. & Date of Certificate (s) held under the Mines Act, 1952, if any:
i. 2nd Class Manager’s certificate No : …………...……… dated: ……………………
ii. Surveyor’s certificate No : …………………………...... dated: ……………………..
iii. Overman/Foreman’s certificate No : …………………. dated: ……………………..
iv. Sirdar/Mate’s certificate No : ………………………..… dated: ……………………..
v. Blaster’s certificate No : ………………….… dated: ……………………..

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 to Year Month Days

be submitted from Directorate of
practical Training.)
(II) In statutory capacity:
(A)As Shot-firer/Blaster Year Month Days
(B) As Sirdar/Mate
(C) As Overman/Foreman
(D)As Second Class Manager
(III) In non-statutory capacity:
A. As Apprentice in Mining Year Month Days
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 (In BLOCK LETTERS): ………………………………………………………………………

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

List of documents to be enclosed:

i. Degree/Diploma /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.
vi. Character certificate.
vii. Fee of Rs: …………..……, Bharatkosh Reference No……………………..…….date…………..……..
viii. Original First Aid Certificate.
ix. Self-Attested copy of Aadhaar
x. Self-attested copies of all documents./certificates.
xi. Self-addressed A-4, size envelope.
xii. An affidavit to the effect that “all the documents or certificates submitted along with the application and
the information provided in the application are GENUINE” -#
xiii. Any other documents as deemed necessary in support of the application.

Date…………… Signature……………………………

# ANY APPLICATION WITHOUT THE AFFIDAVIT SHALL BE SUMMARILY REJECTED.

3
* For Coal Mine -Experience certificate of coal mines with average monthly output less than 1000T/month or 10000m /month shall not be valid.
* For Metal Mine- -Experience certificate of Metalliferous mines with average daily employment less than 60 persons (for belowground mine) or
160 persons (for opencast mine) or 160 persons (In all) shall not be valid. However, In case of opencast mine with less manpower experience
may be considered valid if copy of Heavy Earth Moving Machinery under Regulation 106 of the Metalliferous Mines Regulations, 1961 is
submitted for the experience period.