Schedule I

Form of Application for grant of Certificate of Competency to a person under clause-1 of sub-

rule (3) of Rule 2

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 the Period of Service Designation Area of

Organization Responsibility

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 Competency Certificate is sought (section or sections of the code should

be stated).

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

details)

11. Any other relevant information as demanded by the authority.

Declaration by the applicant: -

I, ................................... , hereby declare that the information furnished above is true.

I undertake

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

my leaving the aforesaid Organization, I will promptly inform The Chief Inspector cum

facilitator of Factories ;

(b) to maintain the facilities in good working order, calibrated periodically as per manuurer’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 of factories 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 organization for the purposes of being

declared as a competent person under the code . I also undertake that I will.

(a) notify The Chief Inspector cum facilitator of factories 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 of factories any change in the facilities (either

addition or deletion)

Signature

Designation

Telephone No

Date: Official Seal

Form of Application for grant of Certificate of Competency to an Institution under Sub Rule

3 of Rule-2.

1. Name and full address of the Organization

2. Organization’s status (specify whether Government, Autonomous, Co-operative,

Corporate or Private)

3. Purpose for which Competency Certificate is sought (specify Section(s) of the code)

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

other statute. If so, give details.

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

in Schedule annexed to sub-rule (3) of Rule 2.

S.N Name and Qualifications Experience Section(s) and the Rules

o. Designation under which Competency is

sought for

1

2

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

maintenance and arrangements made for their maintenance and periodic calibration.

7. Any other relevant information.

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 of competency and

instructions issued by The Chief Inspector cum facilitator of factories from time to

time.

Signature of Head of the Institution or

of the persons authorized to sign on his behalf.

Designation

Place & Date

Form of Certificate of Competency issued to a person or an institution in pursuance to sub

rule-3 of Rule-2

I,….…, in exercise of the powers conferred on me under Section 2(1) of the Occupational Safety,

Health and Working Conditions Code 2020 and the Rules made there under, hereby recognize (Name

of the Institution) or Shri ………………………… (Name of the person) employed in

……………….…………. (Name of the Institution) to be a competent person for the purpose of

carrying out tests, examinations, inspections and certification for such buildings, dangerous

machinery, lifts and hoists, lifting machines and lifting tackles, pressure plants, confined space,

ventilation system and process or plant and equipment as the case may be, used in a factory located

in …………….. under Section and the Rules made there under.

Strike out the words not applicable.

This certificate is valid from ……………..to …………………….

This certificate is issued subject to the conditions stipulated hereunder: -

(i) Tests, examinations and inspections shall be carried out in accordance with the provisions

of the code and the Rules made there under;

(ii) Tests, examination and inspections shall be carried out under direct supervision of the

competent person or by a person so authorized by an institution recognised to be a

competent person.

(iii) The certificate of competency issued in favour of a person shall stand cancelled if the

person leaves the Organization mentioned in his application;

(iv) The institution recognised as a competent person shall keep The Chief Inspector cum

facilitator of factories informed of the names, designations and qualifications of the persons

authorized by it to carry out tests, examinations and inspections.

(v) …………………………………..

(vi) ………………………………….

Station Official Seal Signature of The Chief Inspector cum facilitator Date