FORMAT SUPERVISOR GOVERNMENT OF ANDRAPRADESH A.P.ELECTRICAL LICENCING BOARD APPLICATION FORM FOR ISSUE_OF COMPETENCY CERTIFICATE AND PERMIT TO ‘SUCCESSFUL CANDIDATES IN SUPERVISOR COMPETENCY CERTIFICATE EXAMINATION CONDUCTED BY STATE BOARD OF TECHNICAL EDUCATION AND TRAINING, ANDRAPRADESH, HYDERABAD. Surname 1. Name (Block Letters) 2. Father's Name 3. Age and date of Birth == 4, Educational Qualification : 5, Permanent Address 6. Present Address : 7. Experience : 8. a) Hall Ticket No and Date : (Original Hall Ticket to be enclosed) b) Date ¢) Center of Examination 9. a) Amount of Rs. 85/- b) Challan No. and Date ¢) Place of Payment 10. No, and Date of Power Medicine and First Aid Certificate. 11. Wireman Permit/C.C Are : you having If yesOriginal Wireman Permit and C.C Shall be submitted. Yes / NO Name Photo attested by the principal of Govt. Polytechnic from where appeared for examination12. 4 Specimen Signatures attested by Principal of Government Polytechnic From where appeared for Exams. 1 2 3 4 ATTESTED PRINCIPAL (OFFICE SEAL) Encl Signature of the Applicant DECLARATION thereby declare that the particulars stated above are correct to the best of my knowledge and belief ‘Signature of the Applicant Note :- The application from duty filled in shall be submitted to the Secretary, Andhra Pradesh Electrical Licensing Board, Mint Compound, Stone Buiding, Hyderabad. Accompained by. 1L.An Original Challan for Rs. 200/- (Rupees Two Hundered only) towards the