FORM-A GOVERNMENT OF ANDRAPRADESH ANDRAPRADESH ELECTRICAL LICENCING BOARD APPLICATION FOR FRESH ELECTRICAL SUPERVISOR/WIREMAN PERMIT (LAPSED) (To be filled in English or Telugu) Photo attested by Gazetted Officer Surname Name 1. Full Name of the applicant : (in block letters) 2. Father's Name 3. Date of Birth andage — : 4, Present Adress : 5. Permanent Address 6. 1. Details of Technical Qualification 7. Whether applied for : Supervisor/ Wireman 8. Details of lapsed Prmit No And Date of Lapse Amount of fee remitted: (i) Challan No. Gi) Date. (ii)Treasury (iv) Amount Rs. 9. Four specimen signature of the applicant. 4. 2 8: 4.10.Details of the present status of Employment 11-The following are to be enclosed with this form: a) Proof of Date of Birth : 7 Class /S.S.C /Asst. Civil Surgeon Certificate. b)Treasury Original Challan for the following head of Account: Majar Head 0043 TAXES AND DUTIES ON ELECTRICITY inor Head 102 FEES UNDER CEA(MSES) REGULATIONS 2010 Sub Head 01 FEES UNDER CEA(MSES) REGULATIONS 2010 D.0.0 CODE : 0601-0502-005 ©)Four copies of latest pass port size photographs. d)Power Medicine & First Aid Certificate (Orginal+Xerox copy) €) Stamped self address cover Rs.40/- £) 4 specimen signatures on white paper. &) Proof of address. hy) Identity proof, Thereby declare that the particulars stated above are correct and true to the best of my knowledge and belief Signature of applicant Signed in my presence Counter Signature (Gazetted Officer) Designation Address,CHARACTER AND CONDUCT CERTIFICATE This is to certify that Sri (M) Dist, is known to me since last...... years, His/Her character and conduct is satisfactory as per my knowledge Signature of Gazzeted Officer