Before: The Notary Public at ______________________

AFFIDAVIT

I, _______________________________________________________ S/O :_____________________________________________

aged about : ______ years, by faith :_____________, by occupation :_______________________, resident of
Village :______________________________________________________ Post :______________ Dist :___________________
State :_______________________________, do hereby solemnly affirm oath and declare as follows:-

1. That, information furnished in my application for

______________________________________________________________________________ on dated: ___________
and all the documents and certificates submitted with it are correct and true.

2. That, in case of any documents / certificates / information is/ are found false, I shall be
liable to be punished as per the extant provisions of the Mines Act, 1952.

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

4. That, I am swearing this affidavit before competent authority.

VERIFICATION

Solemnly affirm before me by That the statements made above are true

and correct. I sign this verification at

the _________________________________ _________________________ on ______________

Who is duly identified by Advocate

__________________________________________

__________________________

(Deponent)

NOTARY PUBLIC, ________________________ Identified by

(Advocate’s Signature)