suftrforear, 1952/Mines Act, 1952 Rea # an ir, 1950Me A ci eee rcdaorssee ex saat Saran APPLICATION FORM FOR AGAS TESTING CERTIFICATE. | Wy dere se anager ‘Name of Examination 1 autewan ger arferene at axedt Full name of Applicants (In CAPITAL letters) CBCETrrrt ttt ttre rr tt rrrrrt tii 2, suatammen xa feel /Applicants name in Hind! =a ae SET 3. ayaa Pact aner: Shr/Late/Father's Name: CESErreert tL trrrrrrrrt trite A aero 4 ew( SSCILit Cert.NO.) I I aft (Date) [ Teal 5. ebdomtieat area 6. rom fete (Date of Birth) (Board/ssuing Authority) 1k eh Pert srr frPa/Flame Safety lamp handling Cert. Date 1K ome eteee se ett fae {a1 Amount Indian Postal Order No Date 9 career orn Pat 10, eas wore fet Medical Cert. Date Character Cert. Date 11 eta 5 << SCO tee Examination Centre Statutory Cert 13, fee ar ag et fete ‘Name of Prev. Exam.Centre | Date 14. exer at e/(Mailing Address) ah PIN TS. eet wer/(Permanent Address) VILL. POST PS DIST. “TATE I PIN 6 ih eer Peon fc Hac wen ea ace ew eet Pa enclose original copy of all Certificates/documents in connection withthe above details. 17, sets eet er ferns creat (106m x 22em) a BBO). are fewe reat BY enclose a self addressed envelop (em x 22cm) duly stamped Rs.25/. 18, ae sre efter ereeté econ terse re sabe ete et & | Tenclose three passport size photograph duly attested by Manager. needa? Yours faithfully A cacao reer tor er & Pvatterforr eaett Stoo eet & 1 {solemnly declare thatthe above statements are true. ues Beearere ‘Signature of Applicant 9 woes ee & Rose fer ote Rete A sete 3 Re 7B T certify thatthe above statement have been made in my presence. ruse deere att een/Date Signature & Seal of Manager