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Annexure-A

Mines Manager / Blasting Officer / Surveyor / Overman

GOVERNMENTOF INDIA

MINISTRY OF LABOUR AND EMPLOYMENTDIRECTORATE GENEML OF MINES SAFEW

certificate of practical experience granted by the Manager / owner to a candidate for grant of Manager,s /surveyor's /overman's / Foreman's / Sirdar's / Mate's / diaster's certificate of competency under *the coalMines Regulations ,'1957rzo'r7 / * the Metalliferous Mines Regulations ,.196.r.

the *Manager / Owner

) Mine

belonging to do hereby certify that

Shri/ Kumari/ Smt *Son / Daughter / Wife ofshri ---. '-- --.-_. -- (whose signature is appended), worked in the above mine

from to . During *his/her term of aforesaid work, *he / she has

obtained practical experience as detailed overleaf. The duties connected with *his/her work have involved *his/her continuous

attendance at the mine and have been efficiently performed by *him/her.

I believe *him/her to be of good character, fit and proper person for grant of certificate of competency.

- "'- i;;;;;il;; ;; ;;;;; ; ;;;;;;;il ;;;; ;;; ffi;,";ii

Manager's Certificate No.Name of Mine:Name of Company / Owner:Post Office:

District:

State:

Pin:

(Signature of Candidate)

Note:*Delete whichever is not applicable#(State Name of Mineral)

4:

w

sl.No.

Particulars ofpractical experience

(a)

Place of experience Below ground /Open-cast / Above ground

(b)

Period of Practicalexperience

(c)

Total experience

From To Years Months Days

Grand Total

Duringthe above period In below groundworkings

In open-castworkings

In all

(d) Average MonthlyOutput (FOR COAL MINE)(e) Average Daily Employment(FOR METAL MINE)

(Signature of Candidate) (Signature of Manager / Owner with date and office seal)

Name of Mine:

Instructions: -

(a) (i) Non statutory capacity like general mining / supporting / drilling / blasting / depillaring etc.(ii) Statutory capacity as a Mining Sirdar / Mate / Overman / Foreman / Assistant Manager etc.

(b) State whether above ground or open-cast or below ground working.(c) State specially the period spent by the applicant in different mining operation, or surveying operation as the case may

be, if the employment has not been such as to involve continuous attendance of the applicant at the mine, whether underground or above ground or open-cast and in what capacity.

Note: Experience certificates, not issued by or not having the official seal of the Mine Manager / Owner of the mine, shall notbe valid.*For Coal Mine - Experience certificate of Coal Mines with less than loooT/month or loooomt / month shall notbe valid.*For Metal Mine - Experience certificate of mine with Average Daily Employment less than 60 persons (for below ground mine) or t6opersons (for open-cast mine) or t6o persons (ln All) shall not be valid. However, in case of open-

cast mine with less manpower, experience may be considered valid if copy of Heavy Earth Moving Machinery under Regulation ro6 of theMMR, 1961 is submitted which is valid for the period of experience,

(Annexure - B)

WALK-IN INTERVIEWTO THE FOST OF MINES MANAGER

To,

Chlef Englneer/Fuel,

PSPCl"htlala

o1. FULL NAME (ln Block Letters)

o2. FATHER'S NAME:

o3. ADDRESS:

(a) Permanent:

(b) Present:

o4.DATE OF BIRTH:(Attach self-attested copy ofappropriate certificate)

II(Put'o' before any single digit viz. o5/o7lXXXX)

o5. Age as on or,o4,zo22 ears_month(s)_day(s)

o6.

EDUCATIONAL&

PROFESSTONAL QUALTFtCAT|ON:

(Attach self-attested copy ofappropriate certif icate)

Exam Passed Board / Universlty Year of Passlng jt of Marks

07.Person with Disabllity (pWD):(Rrt r' mark) Yes lNo (tfyestheZofdisabitity) -

o8.

DATE oF AceutRtNG rsr clAssMANAGERS CERTIFICATE OFCoMPETENCY UNDER THE CMR,195il2o17 (if appttcabte)

o9. GENDER:

10. NATIONALITY:

11. IANGUAGESKNOWN:Keao: -Write: -Speaki

12. E-MAILADDRESS:

13. MOBILE NO. / CONTACT NO.:

14.

EXPERIENCE:(Starting with the currentDesignatlon / Organlzation)

(May mention designation wiseexperience separately in details)

Deslgnatlon Organlzatlon From /To Job description

i I n:':lt declare that all statements made in this application are true, complete and correct to the best of my knowledge andi belief' I understand that in the event of any information being found false or incorrect at any stage my candidature is liable to be

cancelled.

Date:

(Slgnature of the Candidate)* for examinations wherein Grade Points / Grades are assigned, convert to nearest percentage of marks.** may attach extrasheets if required.