Form XXXVI

[See Rule - 53(3)]

An application for grant of Certificate of Competency to an Institution under Rule 53.

1. Name and full address of the Organisation........................

2. Organisation’s status (specify whether Government, Autonomous, Co-operative, Corporate or

Private).......

3. Purpose for which certificate of competency is sought (specify section(s) of the Code).

4. Whether the Organisation has been declared as a competent person under this rule or any

other statute and if so, give details.

5. Particulars of persons employed and possessing qualifications and experience as set out in

Schedule ‘E’ annexed to Rule 53;

Section(s) and the Rule under

Serial Name and

Qualifications Experience which certificate of competency

No. designation

is sought for

6. Details of facilities (relevant to Item 3 above) and arrangements made for their

maintenance and periodic calibration.

7. Any other relevant information.

8. Declaration..............

I,………………….hereby, on behalf of ………………….certify the details furnished above are

correct to the best of my knowledge, I undertake to—

(i) maintain the facilities in good working order, calibrated periodically as per manufacturer’s

instructions or as per National Standards; and

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

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

Place :

Signature of Head of the Institution

or of the person authorized to sign on

behalf Designation

Date :