APPICAT1ON 1OIM 1ON AN AUION17A1ON

REGULAT1ON 1M(0) Or
MIIAIIIfTNOU, MINES GUAr1O
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Pa }hn
AOTANS OF APPLICANT:
mEHT
1sumAe.
R VA MA ITO
SR N G N D RA
Na me
0 } . ) nacon 1 n i 1 i n
Fother's name
evidence):1 016 -19 &(1°
Date of Strth &Age (Endose locumenary 7.E a
OU ,
Addresofcandidate Mehaawne T9 a com
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5 Contaxt No 964A6
4adhar
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(Cnclbse Cpy of
Card Nnnher
Aadhar)
STI04-11292

ENGINeeR
6. QUALIFICATTON: M)NIN
PlomA
Mining Enginecrirg
D
. Diploma/Degree
lenager's Perinit Na.

Secord Cass Man ager's

Certilicate No. & date TA
5. be enclot).
Photo copies of the ccrlulicates to
(Self attested Jnd valdity date
date
Foreman 's Certficate No, certificatcs to be enclosedd).
Photo copies of the
(Self attested
No., tate and valid1ty
dulc NIA
5. Mate's Certificate
attested Pho:o copEs).
(Encdose Self examination held: new minE
where last nedcal of permil for è
6. Center and date vith Bharalkosh (lagin
dgms.gov. 1) for grant
deposited onl1ne fee not requirad
Fee Rs. 10/- (RS. Ten) samc mune under
Regulation 346),
or for first time.
In casz cf 1enewal for

Mate/ Forenan)
7. EXPERIENCE:
Period Capaaty(as
Mines
Fra'n To Pal
3-19L2Plm miniss
Sord sJo 3:1%|20
RaTPUT 6-S-1e20-IL20
Kharni a Y K 4
(Enclose documentary evidence)
0)of the Mines Act,
As te:lined in Section 2
8.
Details of Mines
1952 including opencast workings, worksthop,
Mineral benefic alion plant etc.

of the Mine M.L Al S 2eroS 3 harpi ftaln

a) 1Name & ML/QL No.
Numbert1IN) S4 6 2
ij Labour lúentification 14 t |
Return wit
years Annualportel{Return
i) Have youfiledlast
Suvidha'"
online "Shran
unified
Mecember?
period from January to submission id.
if Yes, please indicate
 f No, ream tm

Mine (Openmast PelowaIOU)

oPon cosmjho
bype of
)Fitert ofthe Mu A boy Sod m
(lo)
d Avriage monthly pronho tn
cNo of shis wonkn
nNo of pits oennu() O 2
al Sia M eVCavatio
fret Hoght/Depth
No No. of Excavatum
40
60 30

(inclucding hirexl nac.hinery, a7)

s t ot ach1neries In ue, vilh 1,.

Make & 1ode! fio of

Madunery
S.No machine (Fachmyiinery
Fxcavator O 6
EBLeace wjye Saw 20) S 66
2
pper/ractor 21
2
Drill mc 2]C
coImpressCr 20) (
eY Pump 20 S
10. is Hecnaty used in the mines YES NO 455H P
1. is Compressed ar in use
12. 1s explosve in usc? If so, daly consumpton
13. Ore dress1ng/handl1ng/procesS1ng plant is attacned with the mine No
14. Ref. Of previous perrnission
15 Mode of tansport TYiAler
16. Daily average emplcyrnent in the Mines:
S
Place Male Female Tcta
Surface 2
Opencast TS
|UnderarOund
17. Details of supervisory staff employed in the Mines (Qualified & Unqulified):

Name Designaticn Ccrtificate No. & date of Date of validt

issue
Hima Sinsh_ mons me 02d6,22-s-20 2I- S

I solemnly affim that i am not working in any capacity in ary other mine and the informaten iurushad are
coTea to the best of my knovledge.

Phace
Date Name &Signature of the apohcant.

I/We solernnly affirm that above candidate is employed in our minc and forvard his ppplicat on for Grant o
Managers authoriration
PMaoe: 3 honi lCalo 0A

Date 23- 11 2020

Sgnatureof Kine dineriAK
KmEXH Formt SEN)
. SPAR MINES
Te. , it,-Bhilwara
(Narne & stynature of all partuers in case of partner ship firn1)

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