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APPENDIX H1-A

[See rule 99(1)]

GOVERNMENT OF KERALA

Application for Registration as Architect/Engineer/Town Planner/Supervisor etc. under the Kerala

Municipality Building Rules, 2019

Affix
Passport
Size photo

(One extra copy of the photo

should be separately enclosed
for issuing identity card)

1. Name of Applicant :

2. Permanent Address :

3. Address to which communications

are to be sent :

4. Educational Qualifications
(Attested copies should be enclosed) :

5. Age and Date of Birth

(with proof) :

6. Sex :

7. Experience (Attested copies should be enclosed) :

8 References of previous licenses,if any :

9 Details of show cause notices received/

cancellation of licenses, etc if any :

10 Whether employed in the service of Government :

or Quasi-Government or Government owned
Corporation or Board, Authority or Government
Companies or Banks or not (If so employed
give particulars)

This is a digitally signed Gazette.

Authenticity may be verified through https://compose.kerala.gov.in/
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11 Whether retired from service or not

(If retired, give details) :
(Proof to be attached)

12. Specimen Signature : (i)

(ii)

(iii)

DECLARATION

details furnished above are correct, complete and true to the best of my knowledge and belief.

Name: .
Place:

Date:

This is a digitally signed Gazette.

Authenticity may be verified through https://compose.kerala.gov.in/