Documents for Electrical Supervisor (Mines) Permit - Fresh Grade-1(Having

Supervisor Mines Examination Grade-1 Passed Certificate) applying as

Fresh
1. Single recent passport size photograph.
2. Photo identity proof (Aadhar Card, Voter ID, PAN Card, Ration Card and
DL).
3. Address Proof (Aadhar Card, Voter ID, DL or AFFIDAVIT sworn before
notary for address proof).
4. Medical Fitness Certificate (not later than one month).
5. Specimen Signature.
6. Educational Qualifications: SSLC & Diploma in Electrical Engineering from
Directorate of Technical Education Board or BE in Electrical Engg.
7. Copy of Supervisor (Mines) Grade-1 Examination Pass Certificate.

Documents for Electrical Supervisor (Mines) Permit - Grade 1 (For lapsed

Permits) applying as Fresh
1. Single recent passport size photograph.
2. Educational Qualifications: SSLC & Diploma in Electrical Engineering from
Directorate of Technical Education Board or BE in Electrical Engg.
3. Photo identity proof (Aadhar Card, Voter ID, PAN Card, Ration Card and
DL).
4. Address Proof (Aadhar Card, Voter ID, DL or AFFIDAVIT sworn before
notary for address proof)
5. Medical Fitness Certificate (not later than one month).
6. Specimen Signature.
7. Affidavit-7 sworn before notary.
8. Copy of lapsed Electrical Supervisor (Mines) Grade-1 Permit.

Documents for Electrical Supervisor (Mines) Permit - Fresh Grade-2

(Having Supervisor Mines Examination Grade-2 Passed Certificate)
applying as Fresh
1. Single recent passport size photograph.
2. Photo identity proof (Aadhar Card, Voter ID, PAN Card, Ration Card and
DL).
3. Address Proof (Aadhar Card, Voter ID, DL or AFFIDAVIT sworn before
notary for address proof).
4. Medical Fitness Certificate (not later than one month).
5. Specimen Signature.
6. Educational Qualifications: SSLC/SSC/10th Pass certificate shall be
furnished.
7. Copy of Supervisor (Mines) Grade-2 Examination Pass Certificate.
Documents for Electrical Supervisor Permit - Grade 2 (For lapsed Permits)
applying as Fresh
1. Single recent passport size photograph.
2. Photo identity proof (Aadhar Card, Voter ID, PAN Card, Ration Card and
DL).
3. Address Proof (Aadhar Card, Voter ID, DL or AFFIDAVIT sworn before
notary for address proof)
4. Educational Qualifications: SSLC/SSC/10th Pass certificate shall be
furnished.
5. Medical Fitness Certificate (not later than one month).
6. Specimen Signature.
7. Affidavit-7 sworn before notary.
8. Copy of Supervisor Examination Pass Certificate.
9. Copy of lapsed Electrical Supervisor (Mines) Grade-2 Permit.
 AFFIDAVIT - 7
AFFIDAVIT FOR LAPSED LICENCE /SPECIAL WIRING PERMIT/PERMIT
(RULE 12(3) (6), 19(5) (7), 23(4) (9), 26(5) (7) and 32(3) (7))
(To be executed on stamp paper, as per the Karnataka Stamp Act, 1957)

I. . . . . . . . . . . . . . . . . . . .S/o/D/o. . . . . . . . . . . . . . . . . . . .hereby solemnly affirm

and state as follows.

a) That I am presently residing at. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

b) That I have / had obtained

(i) Electrical Contractor Licence of Super Grade / Class . . . . . . . . .N o. . . . . . . . . .
valid upto.......
(ii) Special wiring permit / Electrical Supervisor / Wireman Permit No. . . . . . . . . .valid
upto ......
c) That the Licence / Special wiring permit /permit so detailed above has lapsed on. . . . .
. . . . . and the same could not be renewed for . . . . . . . . . . reason.

d) That I intend to obtain a new licence/permit in lieu of the lapsed one and state that no
electrical work of the nature detailed under regulation 29 of Central Electricity
Authority ( Measures relating to Safety and Electric Supply) Regulations, 2010, has
been/will be executed by me during the lapsed period

I also state and solemnly affirm and state on oath as follows that whatever stated and
furnished by me as above are true to the best of my knowledge, the breach of which may
entail cancellation of my licence/permit by the department of Electrical Inspectorate who is
being approached by me for issue of the licence/permit.

Specimen signatures
1.

3.

Photo with SIGNATURE OF THE APPLICANT

signature of the

applicant to be SWORN TO BEFORE ME.

attested by the attested by the Notary
Notary
 AFFIDAVIT
DECLARATION FOR ADDRESS PROOF
(To be executed on stamp paper, as per the Karnataka Stamp Act, 1957)

I,…………………………S/o/D/o…………………………….R/o……………………………………………
…………………………………………………………….………………………………………..…. do hereby
solemnly affirm and state on oath as follows:

I, submit that I am residing at…………………………….……………………….…….……………...…..

………………………………………………………………………………………………………………………
…………….…………………………………………………………………………………………………………
……………………………………………………………………………………………………….…………..…

The above stated address is true and this is my signature.

Specimen signatures

1.

3.

Photo with SIGNATURE OF THE APPLICANT

signature of the
applicant to be SWORN TO BEFORE ME.
attested by the attested by the Notary
Notary
 PHYSICAL FITNESS CERTIFICATE

Photo

1. I, do hereby certify that I have examined…………………………………………………

……………………………………………………………….……………….………candidate
for…………………………………………………………………………………………………
………………………… and that I cannot detect that he/she has any disease, constitutional
affection or bodily infirmity except………………………………….………………………..
I do not consider this as disqualification for employment in office of…………………………
……………………………………………………….

2. I'm also satisfied (after personal examination) that he/she was vaccinated/re-vaccinated
within a week prior to the date of this examination

3. Age is according to his/her own statement is ……………………..…………………… year

and by appearance about…………………………………..………….…years.

4. Height…………………………………………….

5. Weight…………………………………………..

6. Chest measurement on (full inspiration)…………………………………………..

7. Vision
Right Eye………………………………………………

Left Eye………………………………………………..

City/Place: SIGNATURE:

Date: Designation: