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

Registration Number

Expiry Date

Which competency is sought, specify also Section / Sections of the Act

Section 28: Lifts and Hoists
Section 29: Lifting Machines, Chains, Ropes, Lifting Tackles
Section 31: Pressure Vessels and Plants

Full Name (Surname First)

Full Address

Telephone No.

Mobile No.

E-mail

Date of Birth

Name of Organisation (If not self employed)

Address of Organisation

Telephone No.

Mobile No.

E-mail

Details of Education Qualification (attested copies of testimonials to be attached.)

Sr.No.	Degree/Diploma	Name of University	Year of Passing
1

Work Experience (Attach certified copies)

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

Details of Facilities available for Examination(for Pressure Vessels & Lifting Machines, etc)

Sr.No.	Name of Instrument/Machine	Make	Date of Purchase	Range	Date of Calibration	Firm from which Instrument Calibrated	Remarks
1

Applicant's Photograph (Max Size : 500KB)

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

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b) My recognition as a Safety Auditor was revoked or cancelled in the past,

FORM OF APPLICATION FOR GRANT OF CERTIFICATE OF COMPETENCY TO A PERSON

DECLARATION