ANNEXURE - V

Last Date of Submission

Registered No.

FORM A

Application for First/Second Class Certificate of competency as Boiler Attendant, under

Andhra Pradesh Boiler Attendant Rules.

Division I Name, etc. of the applicant:

1. Name in full
2. Fathers Name
3. Nationality Affix a recent passport
4. Date of Birth Photograph.
5. Place of Birth
6. Permanent Address
Mailing Present Address
(Mention Door No.
7. Street, Village ,
Post, District.
And Pin Code)
8. Class of Certificate applied for

9. Challan No. . . . . . . . . . . Date . . . . . . . . . . . . Amount Rs.. . . . .

10. Whether appeared in any previous examinations

11. If so admission Card No., Date and Place of Exam

Division II Statement of Service

(The following statement of Services shall be filled by the applicant. Separate SERVICE
CERTIFICATE (S) shall be submitted by the applicant issued by his EMPLOYER (S)
mentioning clearly the Registry No. of Boiler (s), Type , Heating Surface or Rating, Period or
Nature of work performed. The service certificate (s) shall be signed by the Employer, Chief
Engineer or in-charge of the plant.)
 SERVICE OF APPLICANT
Time employed
Sl.No Registr Type Heating Nature of
In this service
. y No. surface work
Fro To Year Month Days
of (rating) Performed.
m
Boiler

Total Service

DIVISION III Particulars of all previous certificates (if any) issued in India

Number Class of If at any time sub Cause of

Where Date of
of Certificat period/cancelled if Date suspension or
issued issue
Certificate e so, state by whom cancellation
1. 2. 3. 4. 5. 6. 7.

Division IV Declaration to be made by the applicant

I do hereby declare that the statements made in Divisions I, II and III of this Form are
correct and true to the best of my knowledge and belief; and that the papers 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 the statements made in
Division II contain a
True and correct account of the whole period of my service with out exception, and I make
this declaration consciously believing the same to be true.

Date at this day of 200

Signature of the Applicant

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Division V Certificate of Compentency

Certified that Shri /Mr ________________________________________has been examined

for certificate of Competency as Boiler Attendent of __________________
Class on this _________________________day of _____________________2001 and
has/has not satisfied us of his fitness to hold a Certificate of Competency as a
________________________________class Boiler Attendant. He has therefore passed/
failed.

Signature of Board of Examiners

ISSUE OF CERTIFICATE

Certificate No.________________________of the ___________________class Boiler

Attendant issued and the duplicate recorded.

Secretary Board of Examiners