Form 22

{See rule 71}

Form of Application for recognition or renewal of recognition to an institution as Third party

Auditor

1. Name and full address of the Institution:

2. Institution status (specify whether Government, autonomous, co-operative, corporate or private)

with registration number:

3. Correspondence Details of institution:

(a) Name of head of Institution

(b) Phone/Mobile No.

(c) E-Mail address

(d) Fax

4. Whether the Institution has been declared as a Third party Auditor by this State or any other State?

If so, give details.

5. Attach bio-data of at least three employed persons, in the Annexure attached to this application:

6. Any other relevant information

7. Certificate No. (in case of renewal)

DECLARATION

I hereby declare that,-

(a) Recognition of the institution as Third party Auditor was not revoked or cancelled by the State

Government in the past;

(b) the recognition of the institution as Third party Auditor was revoked or cancelled in the past, its

details are as follows:

Date of revocation or cancellation

Order number and date:

Period From- To:

Note.- If the recognition was cancelled or revoked twice in the past, the institution is not eligible

for recognition.

(c) The institution has 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 persons whose bio-data it attached to the

application are the employees of the institution whose copies of appointment letters are attached

herewith.

(e) I, --------------------------------------- hereby declare that the information furnished above for ---------

----------------------------- (name of the institution) is correct to the best of my knowledge.

(f) I, …………………………… undertake to,-

(1) notify to the State Government and Chief Inspector-cum-Facilitator immediately, in

case the employed person on the basis of which this recognition was procured when

leaves the employment,

(2) Maintain the facilities in good working order,

(3) fulfill and abide by all the conditions stipulated in the certificate of recognition.

Signature of the Head of the Institution

Designation

Date:

Place:

Annexure:

Personal Information of the persons employed:

1. Name:

2. Father/Husband Name:

3. Date of Birth and Age:

4. Permanent Address:

5. Address for Correspondence:

6. Telephone No.:

7. Mobile No.:

8. Fax :

9. E-mail :

10. Educational Qualification: (Attach Certified copies)

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

DECLARATION

I, ………………………… hereby declare that all information provided in this annexure is true

and correct to the best of my knowledge. If recognized, I agree to abide by and uphold the high standard of

professional ethics in discharge of my duties as a Third party Auditor.

Signature of the Applicant :

Full Name :

Date :

Place :