Form 01

[See rule 4 (6)]

Application for grant of competency to a person

1. Name

2. Permanent and Correspondence Address

3. Date of birth

4. Name of the organization (if self-employed)

5. Contact Details: Email and Mobile No.

6. Educational qualifications (copies of testimonials to be attached)

7. Details of Experience

Name of Period of Service Designation Area of

Organisation Responsibility

8. Memberships, 1f any, of professional bodies

9. (i) Details of facilities (examination, testing etc.)

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

10. Purpose for which competency certificate sought (specify the section of the Code or

rules made there under)

11. Whether the applicant has been declared as a competent person under any other state or

statute (if so, furnish details)

12. Any other relevant information I undertake

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

deletion) I will promptly inform the Inspector-cum-Facilitator.

(b) To maintain the facilities in good working order calibrating periodically as per

manufacturer's instructions or as per National standards; and

(c) To fulfil and abide by all conditions stipulated in the certificate of competency and

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

I ------------------------hereby declare that the information furnished above is true

Place Signature

Date