Form XXXV

[See Rule - 53(3)]

An application for grant of Certificate of Competency to a person

1. Name:

2. Date of Birth:

3. Name of the Organization (if not self-employed):

4. Designation:

5. Educational qualification (copies of testimonials to be attached):

6. Details of professional experience (in chronological order):

Name of organization Period of service Designation Area of responsibility

1 2 3 4

7. Membership, if any, of professional bodies

8. (i) Details of facilities (examination, testing, etc.) at his disposal.

(ii) Arrangements for calibrating and maintaining the accuracy of these facilities

9. Purpose for which certificate of competency is sought (section or sections of the Code

should be stated)

10. Whether the applicant has been declared a competent person under any statute (if so, the

details).........................................

11. Any other relevant information.........

12. Declaration by the applicant...............

I, hereby declare that the information furnished above is true; I undertake?

(a) that in the event of any changes in the facilities at my disposal (either addition or

deletion) or my leaving the aforesaid organisation, I will promptly inform the Chief

Inspector-cum- Facilitator;

(b) to maintain the facilities in good working order, calibrated periodically as per

manufacturer's instructions or as per National Standards; and

(c) to fulfill and abide by all the conditions stipulated in the certificate of competency and

instructions issued by the Chief Inspector-cum-Facilitator from time to time.

Place:

Date: Signature of the applicant

Declaration by the Institution (if employed),

I…………............certify that Shri……………………. whose details are furnished above, is in our

employment and nominate him on behalf of the organisation for the purposes of being declared as a

competent person under the Code. I also undertake that I shall-

(a) notify the Chief Inspector-cum-Facilitator in case the competent person leaves our

employment;

(b) provide and maintain in good order all facilities at his disposal as mentioned above;

(c) notify the Chief Inspector-cum-Facilitator any change in the facilities (either addition or

deletion).

Date:

Signature....................

Designation.................

Telephone No. Official Seal