FORM 1 (APPLICATION FOR GRANT OF CERTIFICATE OF COMPETENCE TO A PERSON) 1. Name 2. Father's Name 3. Date of Birth 4. Address i) Permanent ii) Present 5. Name & Address of the Organization :- 6. Designation :- 7. Education Qualification ( Copies of testimonials to be attested) 8. Details of professional experience ( in chronological order) Name of the Organization Period of service Designation Area of Responsibility 1 2 3 4 9. Membership, if any, of the professional bodies. 10. (i) Details of facilities (examination, testing etc.) at his disposal. (ii) Arrangements for calibrating and maintaining the accuracy of those facilities. 11. Purpose for which competency certificate is sought (Section or Sections of the Act should be stated). 12. Whether the applicant has been declared as a competent person under any statute ( If so the details). 13. Any other relevant information Declaration by the applicant. I, .................. hereby declare that the information furnished above is true. I undertake a) that in the event of any change in the facilities at my disposal ( either addition or deletion ) or my leaving the aforesaid organization, I will promptly inform the chief Inspector of Factories b) to maintain the facilities in good working order, calibrated periodically as per manufacturers instructions or as per National Standards; and c) to fulfill and abide by all the conditions stipulated in the certification of competency and instructions issued by the Chief Inspector of Factories from time to time Place .... Date ..... Signature of the applicant Declaration by the Institution ( if employ*********) I, .............. . certify that Shri ..........is in our employment and we nominate him on behalf of the organization for the purpose of being declared as a competent person under the Act. I also under take that I will -- a) notify the Chief Inspector in case the competent person leaves our employment; b) provide and maintain in good order all facilities at his disposal as mentioned above. c) notify the Chief Inspector of Factories any change in the facilities ( either addition or deletion ). Date : .... Signature Designation Telephone No . Official Seal
