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mu;lx gg (For office use only)OFT : . Received Rs._Mi;j| l. Dy.No._____Rul'd Dated_______

Signature

1 uds-TT dimExam code

2 . fO or ?T dT ijta-ii dimPrev. Y r’s Exam Code

T H E M IN E S A C T , 1952 /etm o f f r a e , 1952 APPLICATION FORM FOR COMPETENCY EXAMINATIONS

UNDER THE MMR 1961 FOR THE YEAR 2016 o f 2 0 1 6 d f d , t i f R q d l ; m n e f ? P l ; e 1961 d v / T f e i s i e r i u js T T d f d , v iU n u u u d

ifrsTT d t u i fOu;Name of examination: Scheme:____________ Subjects

;gT diVrf p i d i ; Affix photograph

here.

2A fO xr ?T dT vib.Mt. u., j y u. .Prev.Yr’s ID No,Roll No & Year

3. VlOnd dT mould App. Surname :4. VlOnd dT UFO , 0 f i d ; UTd (fdoiiom d cM vs-ld _d) First & _Second Name: (In Capital Letters)

4a.VTOnd dT u ie fgUd e Applicants name in Hindi 5 . J t / L O . / fOdT dT OR Shri/Late/Father’s Name:

6. IduM jl L d y / lH U d j id u M j L d y o e m o d l i d frfFi (Date)Sr. SSC/SSC Cert. No.

8 . CM Board:10. OTaTmO.O.Od i .

FAC. No. ______13. u f f Q d d U OeFTOd la

Qualification Cert. No. 16.UTTfUd OOFT i d diM

St.Cert.Code

9 . tu e f f i Date of Birth: n.OeFi i d f f l

FAC DT.: 14.ieT.TUd f f -

Cert. Date

i2 .oo iiy fd d"iu dim15- mdll

Qlf Cv f f f i

lf Code:

19 Cd MTev/HiRd; OiLVd viMj l .Draft/IPO No.

22 . d d v u eo eig e fd dTotal exp. in months

25. tfr.d.UeFT Od Gas testing Cert.No

28. dun dlM

17.OeFT Od i . St.Cert.No.

23.O/TTfUd VUeo Stat. Exp.

20 . f f TDate

__ . Date of passing18.ueTd f f T

Effective Dt

26. t f d u e F r e d T T f F r24.LOTL®; OeFi Od f f l

Med. Cert. Dt.

21. j d eAmount Rs.

Centre Code31.Mailing Address (UdlQR dT idl)

________ G.T.Cert. date29.ey v u eo oeFi ud g ; ugt ?

Exp. Certificate in Original? Yes

27 f d O e F f o d YesNo

. . . Char.Cert.30. e w dim ( d T ju ujlsTT d f d , )

Language Code (Foreman’s exam)

No

PINMobile No. E M ail:

32.Permanent Address: (L-FTi;t OdT),VILL POSTPS DIST

STATE PIN33. DETAILS OF ExPeRiEnCe & SERVICE : v u T ? ' v j ' i d ' dT fOLdd fOoj.l

Name of the mine & owner [T u , ? e ifd d dT u ie

Place of experience VuHU dT LFTTu

Particulars of experience

v u e o d u d i jFrom

lTod d

YY/MM/DDu f / e r g / t n u

d d vu eoT o ta l experience34.VuyxudT dT fOUFT (DETAILS OF ENCLOSURES) 1. 2.3. 4. 5.35. L O -d iW (SELF DECLARATION^ iR ; fdBT l d d ld d jdT g f d m u jo d fOoRV , 0 i p u i , iR ; g II solemnly declare that the above statements and information are true.

VlOnd dT gLOlSR O ffl(S ig n a tu re of the applicant with date)

v u t " I N S T R U C T I O N S

1 .1 ^ wfOfV;i d id Ldlgl l vXth d dM V ld e gt d j t i d lAll the entries should be filled up in black ink in Englishblock letters only.2 .idsiT dlM /fO xr o T d i Hjteri diM/O/iifUd yem i = diM yjtsTT d l d / f O e a HjtsTT d j d / %nf d d y e m h o d i d fddi, t O -SVR/SVUdOaid (H i e a / v U R a ) Surveyor’s (Restricted/Unrestricted),FR/FU- o je M (l l i e a / V l l i e a ), Foreman (Restricted/Unrestricted) MR/MU- eV (l l i e a / V l l i e a ) Mate (Restricted/Unrestricted), Certificate.

(For item No. 1 ,2 &16)3 . fOxr Og dT Vkg.Mt. d., j1 y d. O eg: fOea HjtaiT d l Vlg.dt d., j ld d. O eg fddT ... Prev. Yr’s ID No., Roll No. & Year: Write your Identity No., Roll No. and Year of the exam appeared inprevious year. (For item No. 2A)4 . Id^Mdl L d y / 1 l P i ; j Id-Mdl L d d Hem i = eddT : eTEdtgd fO lidd dT Oeaed HjtaiT Hem HO d t O[dT fdd! l Sr SSC/SSC No: Write number of your Senior Secondary/Secondary School Certificate or equivalen Certificate. (For item No. 6)5 . H i eiEdfgd fO lidd HjtaiT Hem HO d t fOf®T fdd! l Date: Give date of SSC certificate (For item No. 7)6. CTM: cTM dT neged HjtaiT Hem HO HTa d j d Old [ ja i ld dT d ie fdd! l Board: Give the name of the Board/ Institution from where you haveobtained SSC Certificate. (For item No. 8)7. Hem i = frfFT: myplj Hem HO d t OETOT d d - 1 - d d HjtaiT d t f U a fafaT a d g d p lfg , l FAC DT. The validity of First Aid Certificate (FAC) should extend to a date, which is not earlier than the date of exam (For item No. 11)8 . D o f f d " ! d t e tdgtElijt “ d e g ” adT tddteTElijt “ d ip” V lj d te d VTOdd “ F ” fddT l Qlf. Code: Give ‘DEG’ for degree holders, ‘DIP’ fordiploma certificate in mining and mine surveying or F ’ for field candidates (For item No. 12)9. D O f f d " ! Hem i = 1 . : VHd " K d dPdaT t O tdgt, fM dlH! Vlfd Hem HOT d t O[dT fdd l l Qualification certificate N o: Write certificate number of your academic qtalification certificate such as degree, diploma etc (For item No. 13)10 . Hem H= f f : m o jo a "TaTfUd Hem HO d t fafFT f d d l Certificate Date: Give date of abovequalification certificate. (For item No. 14)11 .deT1g fafFT: fd g t/fd d te T Hem HO dT HjtaTlQd TTf O gld d t fOfsT fdd! l Date of passing : Give date of declaration of result ofdegree/diploma certificate (For item No. 15)12 .0 /uR d Hem H= if id l : OETlfdd Hem HO d t Oddi fdd! l St. Certificate No: Give your statutory certificate No. (for item No. 17)13 .HjtaiT " jed d : e d t t t y e .y e . d d ie d d j 50 / - oO dj o M d d f d , d d Mws/HnjOtd e R o d VTMj mOdd hho e d d t fafaT 1 , d 1 f i d Hgd d ! dgt gl 'd l p f , l HtjOd VTMj d t O d d dT , d 1 f i d g d Hj mOd! fOOdT V d e O d d d j l The Bankdraft/IPO r for j 50/- for Surveyor’s/Foreman’s Certificate of Competency Examination, payable to DGMSas fees should be obtained not more than one week before filling up of your application form. If more than one IPO is enclosed, then the details may be given in a separate shee.t (For itemNo. 19)15 O/nfUd VITO Old) OETlfdd HeIDT HO HTa gTd d CTd dT OdTtdd V d ee l Stat. experience: Give statutory experience after obtaining relevant statutory certificate (For item No. 24)16 dun dTM: fdEdfdfdTO d^d I d a dT tdOOTj d j l Centre Code: Use this centre code HYD gddCK Hyderabad, STR d la lj le J j) Sitarampur AJM- V t^ j , Ajmer 16a. dun d1M (d T je i HjtSH d f d ,) Centre code (for Foreman’s Exam only): Use this centre code- DHN- ETdCTd, HYD - §djlCld Hyderabad,NGP- dTOHj, Nagpur, STR — o la ljley j ,Sitarampur, AJM - V t^ j , Ajmer, BHN - jjqd"qj, Bhubneshwar (For item no.28)16. b HTF1Td1M: fdEdfddTO d id dT cdaOTj d j (dT^ee d fd ,) Languate Code-use the following code (For Foreman exam only) EN - V x t tEnglish, HN - fg^dt Hindi, BN - d d id t Bengali, OR - m^tdT Oriya, GU - XtjTOt Gujarati, UR - md Urdu, MR - ejTBt Marathi, TM - afed Tamil, TL - O d J Telugu, ML - ed dT ^e Malayalam, KN - dudM Kannada. (For item No. 30)

17. VUHO e d lOT dT fOLOO fOOj.T: fOpj^T d OdET e ddd HdTj dFTT HTdTfj dT, HIjeda VaTOT V^d CPTO, VdeE11d, d f t d , VEdTHdVTfd dT LHic meddT d j l Details of Experience & Service: Regarding details of experience, clearly mention the type of mines like opencast, underground or other experience like Rescue, Reearch, Planning andteaching etc. (For item No. 33)18. V d dd HHO e fdfdiV L-aTR Hj VHdT gTd dT datp! OdT o ld v1^lyel^.|a djT d j fpHdT, l Affix copy of your recent attested photograph at the space provided in the application form. .VTOdd HHO d naT VHd gTd e [TtP e d dToT d t PTj v1^yel^.|a HfOdT dT [M l OTj 1 , d fddTd e HTjdj O d d d j l o ld d OTed HTaTt dT dTe fd[M s in PTfg, l Application form should be accompanied by four attested copies of your recent photographs, with the name of the candidate written on thefront side, enclosed in an envelope specified for the photograph.20 .VTOdd HHO d OTaT 22 d.^t. x 20 d.^t. VTdTj d dT jOHOT f a fd d lQ MTd fVdV ddT gVT (Hedd j 4 0 / - ) ft O d d d j l Two Self addressed stamped (j 40/-each) envelopes should also be sent along with the application form (sizt22 c.m. x 10 c.m.).21 .edO dpMl VaTaT d t t d lU tla l dT te T d j d aTd V^daTt [Md a U d e 1 952 d y|qElMl d a s a d™d d Huet sTe l Candidates furnishing false information or forged documents shall be liable for punishment as provided under the provision of The Mines Act, 1952.22. v^da1t dT En(rOdtd [n d fOfded 1961 d VEitd cd Hjtan m^Rdef d v | : it fdfdTa Hjtan d f d , fd^T ja v lp l j fddeT dT ht djdT g1eI lCandidates shall abide by the rules governing the conduct of written examination as provided in the examination bye -laws made under the pro visions of Metalliferous Mines Regulations, 1961.23 . VlOdd HHO d OTai VHd O ft d ie t ld l dT bO a js O dealt d j fd d ig d i e t i a [ f d d j fOde d gl l Tie up all your documents withapplication form surely to avoid any inadvertent detachment of youidocuments.24 . p j , jOTjad aaiT VddO HeT°T HO! f t d d t d O d e d HfadT O d d djdT g, d ! NTddj V^d e d t Hei^l H O T/didtiaT d t Vftlyeif.ld HfadTVlOdd HO d OTaT O d d d j l Attested photocopies of all certificates/documents except cha racter, medical and experience certificates which are accepted in original only, should be sent along with the application form25.O ft VHtda Hem ho!, d ie t ia T d aiar ViOdd hho e tP e , [ id d HjtaiT d d , [ i d OjaiT esiR d"iidd , Eidcid - 82600 1 (> i j [ iua ) d d iedOd H t td a d id O gt g a d O ed d V a j O Hit fd VlOdd HO fd d id 2 0 /0 6 /2 0 1 6 a d ygp t l d l Application form along with all required certificates/documents should be sent to the Director of Mines Safety(Exam) & Secretary, Board of M ining Examinations, Directorate General of Mines Safety, Dhanbad-826 001(Jharkhand) by registered post only so as to reach on or before 20/06/2016.