Directorate of Industrial Safety and Health, Maharashtra State :: औद्योगिक सुरक्षा व आरोग्य संचालनालय, महाराष्ट्र राज्य

Form – A (See Rule 6(1)

Application Form For recognition or renewal of recognition of Safety Auditor

(To be filled in by individuals)

Form Type

Registration Renewal

Registration Number

Expiry Date

Name

Father/Husband Name

Date of Birth

Age

Permanent Address

Address for Correspondence

Same as above

Telephone No.

Mobile No.

Fax

E-mail

Educational Qualification (Attach Certified copies)

Sr.No.	Degree/Diploma	College/Institution/University	Year of completion
1

Technical Qualification (Attach Certified copies)

Sr.No.	Degree/Diploma	College/Institution/University	Year of completion
1

Work Experience (Attach certified copies)

Sr.No.	Employment Date From To	Name and address of Employer	Designation	Nature of work
1

Applicant's Photograph (Max Size : 500KB)

Applicant's Signaturec (Max Size : 20KB)

Attach PDF with Certified copies including Educational Qualification, Technical Qualification & Work Experience (Max Size : 500KB)

DECLARATION

I hereby declared that,
a) My recognition as a Safety Auditor was not revoked or cancelled by the State Government in the past;
b) My recognition as a Safety Auditor was revoked or cancelled in the past,