Form 02

[See rule 4 (6)]

Application for grant of competency to an institution

1. Name and full address of the Institution.

2. Contact Details: Email and Mobile number:

3. Institution's status (specify whether Individual, Government, PSU

autonomous, co-operative, partnership, LLP, public or private)

4. Purpose for which competency sought (specify the section of the code or rules made

thereunder)

5. Whether the institution has been declared as a competent person under another statute

or in any other state (if so, furnish details)

6. Particulars of persons employed and possessing qualification and experience

Sl. Name and Qualification Experience Section(s)/rule(s) under

No. Designation which person’s

competency sought

7. Details of facilities and arrangements made for their maintenance

and calibration periodically.

8. Any other relevant information

Undertaking

I……………………. certify that shri………………………………whose details are

furnished above, is in our employee and nominate on the behalf of institution for the purpose

of being declared as competent person under the Code; I also undertake that I will-

(a) Notify to the Inspector-cum-Facilitator in case the competent person leaves our

institution.

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

manufacturer's instructions or as per National standards;

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

deletion)

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

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

I………………………. hereby declare that the information furnished above are

correct to the best of my knowledge

Date

Place Signature Head of Institution