the mines act, 1952 examinations for the coal mines manager's

dk;kZy; mi;ksx gsrq (For
office use only)
izkIr :- Received Rs.___
Mk;jh la- Dy.No._______
fnukad Dated__________
THE MINES ACT, 1952/[kku vf/kfu;e] 1952
APPLICATION FORM FOR COMPETENCY EXAMINATIONS
Signature
UNDER THE CMR 1957 FOR THE YEAR 2012
o’kZ 2012 ds fy, dks;yk [kku fofu;ekoyh 1957 ds v/khu l{kerk ijh{kk ds fy, vkosnu izi=
1 ijh{kk dksM ijh{kk ;kstuk fo’k;
Exam code
Name of examination:____________________ Scheme:___________ Subjects____________
2. foxr o’kZ dk ijh{kk dksM 2Afoxr o’kZ dk vkbZ-Mh-u-] jksy u- o o’kZ
Prev. Yr’s Exam Code
Prev.Yr’s ID No, Roll No & Year
3. vkosnd dk miuke Applicant surname :
4. vkosnd dk izFke ,oa f}rh; uke (fy[kkoV ds cM+s v{kjksa esa) First & Second Name (In Capital Letters)
4a.vkosnd dk uke fgUnh esa Applicant’s name in Hindi
5. Jh@Lo-@firk dk uke Shri/Late/ Father’s Name:
6. lsdsUMjh Ldwy izek.k i= la[;k 6A. frfFk Date
SSC Certificate Number
7. lhfu;j lsdsUMjh Ldwy izek.k i= la[;k 7A frfFk Date
Sr. SSC Certificate Number
8. cksMZ Board: 9.tUe frfFk Date of Birth:
10. izkFk-mi-iz-i= la- 11. izkFk-mi-iz-i= frfFka 12.DokfyfQds”ku dksM
FAC. No. FAC Date 1 Qlf Code:
13. DokfyfQds”ku izek.ki= la- 14 izek.ki= frfFk 15. mRrh.kZ frfFk
Qualification Certificate No. Cert. Date Date of passing
16.oS/kkfud izek.k i= dksM 17.oS/kkfud iz- i= la- 18.izHkkoh frfFk
Statutory Cert. Code Statutory Cert. No. Effective Date
19 cSad Mªk~V@Hkkjrh; iksLVy vkMZj la- 20.fRkfFk 21.jde
Draft/IPO No. Date Amount j
22. ;fn 01@01@1986 ds ckn dh ijh{kkvksa esa fdlh fo’k; esa mRrh.kZ gq, gksa rks fo’k; dksM ,oa o’kZ fy[ksa A
If passed in any subject (s) in Examinations after 01/01/1986, give subject code & year [eg. L. 92 or V. 86]
(a) (b) (c) (d)
23. dqy vuqHko ekg esa fy[ksa 24.oS/kkfud vuqHko 25.LokLF; izek.k i= frfFk
Total exp. in months Statutory Exp. Medical Cert. Date.
26. th-Vh-izek.k i= la[;k 27. th-Vh-izek.k i= frfFk 28 pfj= izek.k i=
Gas testing Cert.No G.T. Certificate date Character Cert.
29. dsUnz dksM 30.ewy vuqHko izek.k i= gS ;k ugh 31. Hkk’kk dksM ¼vkojeSu ijh{kk ds fy,½
Centre Code Exp. Certificate in Original Yes No Language Code (for Overmanexam)
32.Mailing Address (i=kpkj dk irk)
;gka 3-5 ls-eh- x 3-5
ls-eh- vfHkizekf.kr
QksVks fpidk;sa
Affix attested
photograph
(3.5 cm x3.5 cm)
here.
Yes
No
33.Permanent Address: (LFkk;h irk)
VILL
POST
PIN
PS
DIST
STATE
34. DETAILS OF EXPERIENCE &SERVICE : vuqHko vkSj lsok dk foLr`r fooj.k
Name of the mine & owner
[kku ,oa ekfyd dk uke
Place of experience
vuqHko dk LFkku
Particulars of
experience
vuqHko ds izdkj
From
ls
To
rd
PIN
YY/MM/DD
o’kZ@ekg@fnu
Dq vuqHkoTotal experience
35.vuqyXudksa dk fooj.k (DETAILS OF ENCLOSURES): 1. 2.
3. 4. 5.
36. Lo&kks’k.kk (SELF DECLARATION):eSa lR; fu’Bk ls kksf’kr djrk gwa fd mijksDr fooj.k ,oa lwpuk,a lR; gSa A
I solemnly declare that the above statements and information are true.
vkosnd dk gLrk{kj o frfFk (Signature of the applicant with date)