Form 21

{See rule 71}

Application form for recognition or renewal of recognition of Third party Auditor

(to be filled in by individuals)

1. Name:

2. Father/Husband Name:

3. Date of Birth and Age:

4. Permanent Address:

5. Address for :

(a) Correspondence-

(b) Telephone No. :

(c) Mobile No. :

(d) Fax :

(e) E-mail :

9. Educational Qualification : (Attach Certified copies)

[Sr.No/ Degree/Diploma College/Institution/University Year of completion]

10. Applicant’s Latest Photograph signed across.

11. Technical Qualification in Safety (Attach certified copies)

[Sr. No/ Degree/Diploma College/Institution/University Year of completion]

12. Work Experience (Attach certified copies)

[Sr. No/ Employment Date/ Name and address of Employer /Designation/ Nature of work/From -

To]

13. For renewal of recognition.-

Certificate No. and date:

DECLARATION

I hereby declared that,

(a) my recognition as a Third party Auditor was not revoked or cancelled by the State Government

in the past;

(b) my recognition as a Third party Auditor was revoked or cancelled in the past, and its details are

as follows :-

Date of revocation or cancellation

Order number and date, if any

Period From- To

Note.- If the recognition was cancelled or revoked twice in the past, the Third party Auditor is not

eligible for recognition.

(c) I have carried out three or more than three, Audits in the past two years, the list showing the

name, address of the factory and date of audits are attached herewith.

(d) I, ------------------------------------------ hereby declare that the information furnished above are

correct to the best of my knowledge.

I, ………………………………. undertake to:

(iii) Maintain the facilities in good working order, and

(iv) Fulfill and abide by the conditions, if any, stipulated in the certificate of recognition.

Date:

Signature of the Applicant

Place: Full

Name: