Application Form for Electric Contractor License Category "C"

FORM “C”APPLICATION FOR ELECTRICAL CONTRACTOR LICENSECATEGORY “C”.1. Name & Address of the Applicant ________________________________________________________________________________________________________________________2. Description of the Commercial Premises. _________________________________________3. Nature of business __________________________________________________________4. Name, Designation & NIC No. of the applicant/partners authorized to signdocuments_______________________________________________________________________________________________________________________ (attach attested copy of NIC)5. Financial Position supported by Bank Statement for the preceding year _________________6. National Tax Number (NTN). ________________________________ (attach attested Copy).7. Detail of previous Contractor’s License if held ____________________________________8. Names, Academic & Technical Qualification of the Applicant/Partners.(Attach separate sheet).9. Name of holder of Certificate of Competency on the strength of whose the contractors Licenseis being sort _______________________________________________________________10. Particulars of Testing Instruments (Complete Annex. ‘C-1’ & attach original purchase receipts).11. Detail of staff employed (Complete Annex. ‘C-1’ & attach attested copies of certificates and NIC)12. Fee Rs. 1000/-paid into NBP ___________Branch /vide treasury receipt No. __________Dated __________ (Attach original copy).I/We _____________________________________________________ hereby declare that:-i) Particulars stated above and filed in the Annex ‘C-1’ is correct to the best of my/our knowledge.ii) I/We fully understand the terms and conditions under which license is granted (attach duly signedcopy of terms and conditions).iii) I/We shall submit works commencement and completion reports on the prescribed proforma.iv) I/We shall supply regular return on any change occurred in the above particulars.iii) I/We shall comply with the instruction issued by Electric Inspector for the compliance ofprovisions of Electricity Act, 1910 and Electricity Rules, 1937.Dated: _____________________Signature: _________________________(Official seal of the Company)...................................................................................................................................................................(For Official Use Only)Instruments Inspected by:Name/Designation _________________________Signature: _______________________________Documents checked by:Name/Designation: ________________________Signature: _______________________________Page 1 of 2

PARTICULARS OF TESTING INSTRUMENTSAnnex: ‘C-1’(I). Megger (1000 V): Make: ____________________________Maker’s No: _______________________Range: ___________________________(II). Earth Tester: Make: ____________________________Maker’s No: _______________________Range: ___________________________(III). Clamp on Meter: Make: ____________________________Maker’s No: _______________________Range: ___________________________(IV). Safety Gloves Make: ____________________________(V). Helmet Make: ____________________________PARTICULARS OF THE TECHNICAL STAFF EMPLOYEDDIPLOMA HOLDER:1. a) Name:____________________________________ Father’s Name:_________________b) Qualification:______________________ (attach attested Copies of diploma and certificate of competency)c) Certificate of employment ______________________________________ (Attach Copies)ELECTRICIAN/WIREMAN1. a) Name:________________________________ Father’s Name:_____________________b) Qualification: ___________________________________(attach attested Copies of Permit)c) Certificate of employment ______________________________________ (Attach Copies)Dated:____________________________Signature of ApplicantPage 2 of 2