APPLICATION FORM App.

No: 238934

11th NATIONAL CERTIFICATION EXAMINATION

FOR ENERGY MANAGERS/ ENERGY AUDITORS-Feb-2011
( Under the Energy Conservation Act, 2001 )

Examination you are appearing for: Energy Auditor

Candidature: Self-Sponsored
Please Affix Your Specimen Signature :

For Office Use Only

Exam Fee Particulars : ( DD should be in favour of "Bureau

of Energy Efficiency" payable at 'Chennai')
Bank
Amou ICICI BANK, RATLAM
Rs. 10500 Name,Place
nt : KOTHI, INDORE, M.P.
:
DD
004676 Date : 21/12/2010
No :

Regn. No. _________________________ Affix a Self

Attested recent
passport size photo
Remarks if any

_______________________________________________________
____

Controller of Examination

1. Name of the
Abhishek Lodhi
Applicant:
2. Father's Name: Mr JP Lodhi
3. Present Address: 4. Permanent Address
Flat No 101, S/o Mr JP Lodhi, Plot No 87,
43, Latest Plaza, Nav Adarsh Colony,
Srinagar Extension MR-4 Road,

City: 452001 Jabalpur

City:
PinCode: Indore PinCode: 482002

State: Madhya Pradesh Madhya Pradesh

State:

5. Date of Birth: 6/7/1984 Indian

6. Nationality:

7. Community: General Male

8. Sex:
9. Employment Status: Employed

10. Present Company Address:

Designation: Senior Operation Officer
Company Name: Bharat Petroleum Corporation Ltd.
Mumbai-Manmad
Bijawasan Pipeline
Manglya Installation,
Sanwer Road
City: 453771PinCode: Indore
State: Madhya Pradesh

11. Total Work Experience: 3Yrs 8 Months

12. Contact Telephone. Fax, Email: Mobile: 9981166018
Office Phone: 9425065623 Fax:
Res. Phone: Email: abhisheklodhi@gmail.com
13.Examination Centre:
a) Written Examination
1.Bhopal 2. Jabalpur 3. Nagpur
Centre:

14. Requisite Educational Qualification

Nameof
Year of
Slno Degree/ Subjects/ Branch Board / University
Passing
Diploma
 Bachelor of
1 Electrical 2006 RGPV Bhopal
Engineering

15. Requisite Experience for fulfilling the eligibility criteria

Name of Employer/ Year

Slno Designation Nature of Work
Organisation
From To
Bharat Petroleum Senior Operation Handling operations in
1 2/4/2007 23/12/2010
Corporation Ltd Officer Cross Country Pipeline

Declaration by the Candidate

I hereby declare that all the information given in the application form and enclosures
are true to the best of my knowledge. I agree to the condition that if any information
or any statement is found to be incorrect, my registration to the examination would be
cancelled. I also understand that it is my responsibility to cross check information from
the websites as mentioned in the prospectus for the allotted examination centre and
issue of hall ticket. I shall inform NPC Chennai about any change in my mailing
address, telephone number and e-mail ID, if any, at the earliest. I also abide by the
examination scheme and conditions as mentioned in the prospectus.

Place: INDORE Signature

Date: 23/12/2010 Name Abhishek Lodhi

Note:
(i) Application Form received with incomplete particulars will be rejected
(ii) Allotment of Registration Number and Issue of Hall Ticket are subject to receipt of this form
duly signed by the applicant along with required documents and Demand Draft on or before
the last date at the Office of the Director and Controller of Examination, Dr.Ambedkar
Institute of Productivity (NPC), 6, Sidco Industrial Estate, Ambattur, Chennai-600 098

List of Enclosures to be attached with the Please

Application: tick

1 Proof for requisite educational qualification.

(Certificate should be attested by a Gazetted
Officer / Employer) *

2 Proof for requisite experience (Excepting the

Supplementary Candidates and candidates
applying for up gradation of EM certificate to EA
certificate, who have already submitted the
 Experience Certificates). *
(Candidates should have acquired the
requisite number of years of work
experience as on 5thJanuary 2011.
Candidates will be registered and
guidebooks will be sent only on receipt of
Experience Certificate for which the last
date will be 5th January 2011. Candidates
without requisite work experience are not
eligible to register for the examination.)

3 One common DD for Application fee and

Certification fee in favor of Bureau of Energy
Efficiency payable at Chennai. (For
supplementary candidates and candidates
applying for up gradation of EM certificate to EA
certificate there is no application fee)*

4 The self-employed candidates should attach

proof for atleast two major works carried out
for the clients. (Attach either work order or
letter from the clients). In addition the
candidates should attach photocopies of the
Income tax returns for a minimum period of
two years.*

5 Affix one self-attested recent passport size

photograph in application form *

6 Proof of SC/ST/OBC certificates as per Govt. of

India format in case of claiming fee
concession.Certificates issued in local
languages will not be accepted. *

7 Proof of Income certificate for self sponsored

candidates in the category of OBC & having
annual income not more than Rs. 4.5
Lakh/Annum*
* These enclosures are a MUST for
Registration