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Application Form On Exemption Basis-COAL

                                                                                    FOR COAL
Application form to be filled in by a candidate for obtaining a 2nd Class Manager’s (R), 2nd Class Manager’s (UR), Overman (R), Overman (UR), Surveyor (R), Surveyor (UR) certificates of competency on Exemption basis.


Full Name (As per
Matric certificate in
Capital Letters)
2. Father’s/Husband’s:
full name (in
Hindi)
.....................................................................................

.....................................................................................
.......................................................................................

......................................................................................
3. Date of birth : ..........................................................................................
4. Category : SC / ST / Others (Strike out which are not applicable)
5. Mailing
Address

: ..........................................................................................
...........................................................................................
...........................................................................................
...............................................................Pin........................

6. Permanent Postal
Address:

: Village : ........................... Thana :....................................
P O : ................................ Dist : .....................................
State : .............................. .................. Pin ............................
7. Qualifications : a) Date of Passing /Degree /Diploma: ......................... ..............
b) No. & Date of Certificate: ....................................................
c) Name of Institution from which Qualified: ..............................

8. Gas Testing
Certificate
(If applicable)
9. First Aid
Certificate

: a) No.: ........................................ Date of Issue ......................
b) Date of Passing ..................................................................

: Type ................No...............................Valid upto..................
PTO

The Mines Act, 1952

APPLICATION FORM FOR CERTIFICATE OF COMPETENCY

ON EXEMPTION BASIS
UNDER THE CMR, 2017

10. No. & Date of Certificate (s) held under the Mines Act, 1952, if any:
i. 2
nd Class Manager’s certificate No: ..................... dated: .........................
ii. Surveyor’s certificate No: ................................. dated: .........................
iii. Overman’s certificate No: ............................... dated: ..........................
iv. Sirdar’s certificate No: ..................................... dated: ..........................
11. Training: Period of practical experience* gained in different mines with actual date of

commencement /termination.
(I)As P.G.P.T / P.D.P.T/Practical training
(as worker/employee etc.)
(II) In statutory capacity:
(A)As Shot-firer
(B) As Sirdar
(C) As Overman
(D)As Second Class Manager
(III) In Non-statutory capacity:
A. As Apprentice in Mining
B. As Apprentice in Surveying
C. As Surveyor

Year Month Days
Year Month Days

Year Month Days

Total :
12. Mobile Number (10 digits only): ............................................................
13. E-mail ID (In BLOCK LETTERS): .................................................................................
14. Aadhaar No. : ...........................................................................................
List of documents to be enclosed:
i. Original & Self-Attested copy of Degree Certificate & Mark sheet / Diploma Certificate & Mark sheet.
ii. Original & Self-Attested copy of Matriculation Certificate
iii. Original & Self-Attested copy of Post Graduate / Post Diploma practical Training certificate in prescribed
format in Mining.
iv. Original & Self-Attested copy of Valid First Aid Certificate
v. Original Medical certificate of fitness in prescribed format.
vi. Original Character certificate in prescribed format.
vii. Fee of Rs: ...................., Bharatkosh Reference No.................................date......................
viii. An affidavit to the effect that “all the documents or certificates submitted along with the application and
the information provided in the application are GENUINE”#
ix. Two duly attested passport size Photographs with name written clearly on the front (top) side.
x. Self-Attested copy of Aadhaar
xi. Self-addressed A - 4, size envelope.
xii. Any other documents as deemed necessary in support of the application.
Date............... Signature.................................
Note:
# ANY APPLICATION WITHOUT THE AFFIDAVIT SHALL BE SUMMARILY REJECTED.
Experience certificate of below ground coal mines producing less than 1000 tonnes per month (of coal) or
less than 10000 cubic meters per month of material handled (in an opencast mine) is not be valid.

16-12-2019    0