(For office use only)

Dy.No. खान अ ध नयम, 1952 / The 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
UNDER THE MMR, 1961 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 (R), 2nd
Class Manager’s (UR), Foreman (R), Foreman(UR), Surveyor (R), Surveyor (UR) certificate of
competency on Exemption basis. (Strike out whichever is not applicable)

1. Full Name (As per ………………………………………………………………………….

Matric certificate in
Capital Letters)
vkosnd dk uke :
………………………………………………………………………….
( fgUnh esa )
2. Father’s/Husband’s: …………………………………………………………………………...
full name (in
Hindi)
firk/ ifr 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. Foreman’s certificate No : …………………. dated: ……………………..
iv. 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 be submitted Year Month Days

from Directorate of practical Training.)
(II) In statutory capacity:
(A)As Blaster
(B) As Mate Year Month Days
(C) As Foreman
(D)As Second Class Manager
(III) In non-statutory capacity:
A. As Apprentice in Mining
B. As Apprentice in Surveying Year Month Days
C. As Surveyor
D. In Research Work
E. In Teaching
F. In Planning
Total :
Details of Permission for use of Heavy Earth Moving Machinery granted under Regulation 106 of the MMR, 1961 (If
applicable): Letter No._________________________________________________ date __________ ; Valid for __________ Years
12. Mobile Number (10 digits only): ……………………………………………………

13. E-mail Id (In BLOCK LETTERS): ………………………………………………………………………

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

List of documents to be enclosed:

i. Original & Self-Attested copy of Degree Certificate & Mark sheet / Diploma Certificate & Mark sheet
ii. Original & Self-Attested copy of Matriculation Certificate
iii. Original & Self-Attested copy of Post Graduate/Post Diploma practical Training certificate* in prescribed
format in Mining.
iv. Original & Self-Attested copy of Valid First Aid Certificate
v. Original Medical certificate of fitness in prescribed format.
vi. Original Character certificate in prescribed format.
vii. Fee of Rs: ……..…, Bharatkosh Reference No……………………………………..…….date………..……..……..
viii. 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” -#
ix. Two duly attested passport size Photographs with name written clearly on the front (top) side.
x. Self-Attested copy of Aadhaar
xi. Self-addressed A-4, size envelope.
xii. Any other documents as deemed necessary in support of the application.

Date…………… Signature……………………………
Note:
# ANY APPLICATION WITHOUT THE AFFIDAVIT SHALL BE SUMMARILY REJECTED.
* 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 permission for use of Heavy Earth Moving Machinery granted under Regulation 106 of the Metalliferous Mines Regulations, 1961
is submitted for the experience period.