Part - IV : DECLARATION TO BE MADE BY THE APPLICANT

I MAHADEV GURAPPA KOVALLI do hereby declare that the statements made in part I, II and III of this Form are
corrected and true to the best of my knowledge and belief; and that the papers enumerated in part II and
submitted with this form are true and genuine documents and further that the copies of the documents
submitted with this form are true and correct account of the whole period of my service without exception, and I
make this declaration conscientiously believing the same to be true.
Date at ............... this 15 day of Oct 2018
Application Number: E0012018-20190004355

Signature of the applicant

Present Address: Essar POwer Hazira Ltd, 27km Hazira Road Surat,Gujarat,India - Surat City - Surat

Note:
1. Every application must be accompanied with the requisite fee in the manner as may be prescribed By the government.
2. Two copies of a recent bust photograph of the applicant ( size 50mm x 65mm ) must accompany the application with applicant's signature on the
back.
3. Any person making a false statement for the purpose of the admission to the examination renders himself liable to prosecution.
4. Incomplete application is liable to be rejected.
5. Application with this declaration form and all attached testimonials must be submitted on or before 30/08/2018 at nearest boiler office in
Gujarat.

Part - V
(Not to be filled by the applicant)
Certified that Shri MAHADEV GURAPPA KOVALLI has been examined for Certificate of Proficiency as Boiler
Operation Engineer and that he has passed/failed in the examination held during______________________________.

Personal identification mark on Body.

Signature of Board of Examiners

Issue of Certificate of Proficiency as Boiler Operation Engineer when certified to have passed certificate
No._____________issued on ___________________and duplicate record.

Secretary
 Board of Examiners
 
Application Number: E0012018-20190004355

Exam Type: Boiler Operation Engineer

Applicant Name: MAHADEV GURAPPA KOVALLI
Address: Essar POwer Hazira Ltd, 27km Hazira Road Surat,Gujarat,India - Surat City - Surat
Attached Document: School Leaving Certificate / Birth Certificate,Degree/Diploma Certificate,HSC/SSC/Marksheets/Certificate,Experience
Certificate,Character Certificat

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