Images

Application On Exemption Basis- Metal

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

1. 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


APPLICATION FORM FOR CERTIFICATE OF COMPETENCY

ON EXEMPTION BASIS
UNDER THE MMR, 1961

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. Foreman’s certificate No : ...................... dated: ..........................
iv. Mate’s certificate No : ................................ dated: ..........................
v. Blaster’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. ( Certificate to be submitted
from Directorate of practical Training.)
(II)In statutory capacity:
(A)As Blaster
(B) As Mate
(C) As Foreman
(D)As Second Class Manager
(III) In non-statutory capacity:
A. As Apprentice in Mining
B. As Apprentice in Surveying
C. As Surveyor
D. In Research Work
E. In Teaching
F. In Planning

Year Month Days

Year Month Days

Year Month Days

Total :

Details of Permission for use of Heavy Earth Moving Machinery granted under Regulation 106 of the MMR, 1961 (If
applicable): Letter No._________________________________________________ date __________ ; Valid for __________ Years
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 Metalliferous mines with average daily employment less than 60 persons (for belowground mine) or 160 persons (for opencast mine) or 160 persons (In all) shall not be valid. However, In case of opencast mine with less manpower experience may be considered valid if copy of permission for use of Heavy Earth Moving Machinery granted under Regulation 106 of the Metalliferous Mines Regulations, 1961 is submitted for the experience period.

16-12-2019    0