CHIEF ELECTRICAL INSPECTOR AND COLLECTOR OF ELECTRICITY DUTY

Secretary Licencing Board, Gujarat

Application Form For Exemption From Electrical Supervisor Examination (Form A3)
Application No.: 20210813-SUPEXM-UPUS3 Date:: 09/10/2023

DARSHIT HARISHCHANDRA VYAS

B/36 TRISHA DUPLEX NEAR HOTEL AIRPORT
HARNI ROAD
VADODARA
1 Full name & address of applicant (Mobile No. and Email ID.) Taluka : VADODARA
District : VADODARA
GUJARAT, 390022
Mobile No. : 9727595557
Email Id. : darshitvyas007@gmail.com

Date of Birth and age 28/09/1996, Age: 27 Years

2
(Submit attested copy of school leaving certificate) School Certificate : LC.PDF

Degree In Electrical Engineering

3 Technical Qualification (Submit attested copy of certificate) Certificate: Degree Marksheet.PDF, Degree
Certificate.PDF

Detail of past and Present service (date of commencement and

4 NA
termination of each appointment to be given)

Chalan No. : 57000013551004309102392497

Fees( as prescribed in Regulation - 48) payable in government Chalan Date: 09/10/2023
5 treasury/ State bank of India Amount : Rs 500.0
Fees for exemption from electrical supervisor exam Bank Name : SBIEPAY
Place : VADODARA

Declaration for exemption of electrical supervisor permit in Gujarat state

I hereby declare that I have not holding any supervisor permit issued by Gujarat state or any other state.
Myself is liable for prosecution for false information

Date:
Applicant Signature:

In Presence of ( as per Note:3)

I hereby declare that the particular stated above are correct and true to the best of my knowledge

Name: Signature: Designation:

Date:

Note :-
1. Submit attested copy of all certificates
2. No payment will be accepted in cash or cheque. Fees must be paid into a Government Tresury or the State
Bank Of India in the Gujarat State.
3. The application must be signed in the presence of the employer, an honorary magistrate, or a Government
official.
4. Two copies of the latest photograph of the Applicant ( Size 5*6.25 cms) to accompany the application with
name on the back.(Attested by an Honorary Magistrate, or a Government official).
5. Any person making false statements for the purpose of Exemption from Electrical Supervisor Exam shall
render himself liable for prosecution.
6. Details of past and present service. (Date of Commencement and termination of each appointment to be
given) testimonials, original and copies thereof, to be submitted.
7. Incomplete application will be rejected.

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