THE BOILER OPERATION ENGINEERS RULES, 2011.

FORM - A
(See rules 26 and 41)

APPLICATION FOR CERTIFICATE OF PROFICIENCY AS BOILER OPERATION ENGINEER

PART- I NAME ETC. OF THE APPLICANT
Note :1. 2. Every application must be accompanied with the requisite fee in the manner as may be prescribed by the Government. Two copies of a recent bust photograph of the Applicant (size 50 mm x 65 mm) must accompany the application with Applicants signature on the back thereof, duly attested by a Gazetted Officer or the Candidates Employer. Any person making false statement for the purpose of admission to the examination renders himself liable for prosecution. Incomplete application is liable to be rejected.

3.

4.

1. Name (In Full) 2. Fathers Name 3. Nationality 4. Date of Birth 5. Place of Birth 6. Permanent Address :

7. Whether appeared in any previous examination 8. If so, details of Place and Date:

PART - II
PARTICULARS OF ALL CERTIFICATES SUBMITTED
Date of Issue 4 5 6 7 If at any time suspended or cancelled, and if so state by Whom Date of Suspension or cancellation Reasons for Suspension or Cancellation

Number of the Certificate 3

Class of Certificate

Place of Issue

PART - III

LIST OF TESTIMONIALS AND STATEMENTS OF SERVICE

(The Testimonials to be Numbered Serially Corresponding to the Numbers given in column 1 below)

Date of TestimoTestimonials nials Service of Applicant Period for which employed

Sl.No. of the Capacity in which employed

Name of the person signing the Testimonials

Address and Designation of Factory or workshop where employed

Number, Type and Heating Surface of Boilers worked on

Not to be filled in by the Applicant

Date of Commencement Date of Termination 8 9 4 5 6 7

Years Months Days 10 11

Initial of Remarks verifier 12 13

Total Service : :

______ Y_____M_____D_____ ______ Y_____M_____D_____ ______ Y_____M_____D_____

Time Served for which Certificate are produced

Time Served for which No Certificate are produced

PART IV DECLARATION TO BE MADE BY THE APPLICANT

I do hereby declare that the statements made in Part I,II and lll of this Form are correct and true to the best of my knowledge and belief and that the papers enumerated in Part ll and submitted with this form are true and genuine documents and further that the copies of the documents submitted with this form are true and correct. I further declare that statements made in Part III contain a true and correct account of the whole period of my service without exception, and l make this declaration conscientiously believing the same to be true.
Dated at ..........................................this................................. day of ............................ 201 Signed in the presence of Signature & seal Name : Designation: Contact No : Address : Signature of the Applicant Contact No: Present Address:

PART V
(Not to be filled by the applicant)

Certified that Shri ....................................................................................................has been examined for the Certificate of Proficiency as Boiler Operation Engineer and that he has PASSED/FAILED in the Examination held during .................................... Issue of Certificate of Proficiency as Boiler Operation Engineer when certified to have passed. Certificate No. : ........................................................ Issued on : ..................................... and duplicate recorded BOARD OF EXAMINERS : 1. 4.

2.

5.

3.

6.

SECRETARY

CHAIRMAN 4