FORM 'A'

[See rules 26 and 42 of the Boiler Attendant's Rules - 2011]

APPLICATION FOR SECOND CLASS BOILER ATTENDANT EXAMINATION

PART - I: NAME ETC OF THE APPLICANT

Application Number TSBA/SC/2023/0352

1. Applicant Aadhaar Card Number 914550047338

2. Name of the Applicant (in full) KUKKALA THIRUPATHAIAH

3. Applicant Father's Name K ANJANEYULU
4. Mobile Number 9160322352
Photo
5. Email id thirupathi9160322352@gmail.com
6. Nationality INDIAN
7. Date of Birth 16/09/1996 & Age: 26
AJJAKOLU VILLAGE KOTHAKOTA MANDAL
8. Place of Birth
WANAPARTHY DIST TELANGANA
9. Permanent Address:
i) H.No / Door No. 1-98/1
ii) Locality AJJAKOLU VILLAGE
iii) Village AJJAKOLLU
iv) Mandal KOTHAKOTA
v) District WANAPARTHY
vi) State TELANGANA
vii) Pincode 509110
10. Present Address: Same as Permanent Address
i) H.No / Door No. 1-98/1
ii) Locality AJJAKOLU VILLAGE
iii) Village AJJAKOLLU
iv) Mandal KOTHAKOTA
v) District WANAPARTHY
vi) State TELANGANA
vii) Pincode 509110
11. Height (without shoes) 167
i) A MOLE ON THE RIGHT HAND
12. Marks of Identification
ii) A MOLE ON THE LEFT HAND
13. Whether appeared in any
No
previous examination:
Challan No.: 6300714807, Amount: 300, Payment
14. Payment Details
Date: 28-05-2023
 PART - II: PARTICULARS OF ALL CERTIFICATES SUBMITTED

If any
Suspended Date of Reason of
Number time
Class of Date of or suspension suspension
of the Place of issue suspended
certificate issue Cancelled or or
certificate or
by whom cancellation cancellation
cancelled
1 SSC AJJAKOLU VILLAGE 21/05/2011 No
NSL KRISHNAVENI
SERVICE SUGARS LTD
2 15/05/2023 No
CERTIFICATE RAMAKRISHNAPURAM
VILLAGE KOTHAKOTA
 PART - III: LIST OF TESTIMONIALS AND STATEMANTS OF SERVICE

(The testimonials to be numbered serially corresponding to the numbers given in serial number column below)
Number, type
Serial Name of and heating Capacity in
Date of Address and designation of factory or
number of person signing surface of which
testimonials workshop where employed
testimonials testimonials boilers worked employed
on
DY.MANAGER OF NSL A.P 6043
KRISHNAVENI SUGARS LTD, HEATING
1 15/05/2023 K SUDHAKAR RAMAKRISHNAPURAM VILLAGE SURFACE 50
KOTHAKOTA MANDAL, AREA IS 3486
WANPARTHY DIST, TELANGANA M^2
Period for which
Service of applicant Not to be filled by the applicant
employed
Date of joining / Date of Initials of
Years Months Days Remarks
commencement termination verifier
19/01/2018 5 3 27
Total Service Years: 5 Months: 3 Days: 27
Time served for which certificates are produced Years: 5 Months: 3 Days: 27
Time served for which no certificates are
Years: 0 Months: 0 Days: 0
produced
 PART - IV: DECLARATION TO BE MADE BY THE APPLICANT

 I do hereby declare that the statements made in Part I, II and III of this Form are correct and true to the best of my
knowledge and belief; and that the papers enumerated in Part II and submitted with this form are true and genuine
documents and further that the copies of the documents submitted with this form are true and correct. I further
declare that the statements made in Part III contain a true and correct amount of the whole period of my service
without exception, and I make this declaration conscientiously believing the same to be true.

Dated at 28/05/2023

Signed in the presence of Signature of the applicant    

Present address:...............................

.........................................................

Signature................................ .........................................................

Designation.............................. ........................................................
NOTE:
1. Every application must be accompanied with the requisite fee in the manner as may be prescribed by the
Government.
2. Two copies of a recent bust photograph of the applicant (size 50mm X 65mm) must accompany the application
with applicant's signature on the back thereof, duly attested by a Gazetted Officer or the candidate's employer.
3. Any person making a false statement for the purpose of admission to the examination renders himself liable to
prosecution.
4. Incomplete application is liable to be rejected.
 PART - V

(Not to be filled by the applicant)

Certified that Shri KUKKALA THIRUPATHAIAH has been examined for Certificate of Competency as SECOND
CLASS Boiler Attendant and that he has passed/failed in the examination held during
____________________________

* Personal identification mark on Body

Signature of Board of Examiners

 Issue of Certificate of Competency as SECOND CLASS Boiler Attendant when certified to have passed
Certificate No._______________________________________________________ issued on
_________________________________________ and duplicate recorded.

Secretary
Board of Examiners
 (Annexure - 1)

CERTIFICATE OF PHYSICAL FITNESS

 I, do hereby certif. that I have examined (Full name) Sri KUKKALA THIRUPATHAIAH S/o K
ANJANEYULU a candidate for Boiler Attendant SECOND CLASS and cannot discover that he has any physical
deformity or blindness of one or both eyes or deafness or stammering or other defect of speech. I further certify that I
cannot discover that he has any disease communicable or otherwise constitutional affection of bodily infirmity except
his weight is Excess / Below of the standards, or except ................................................

  I do consider this a disqualification to perform duties of boiler attendant.

  I do further certify that is my opinion general physical condition in such as to enable him perform efficiently the
active duties of Boiler Attendant.

  His age is according to his own statement 26 years and by apperance about 26 years. I also certify that he has
marks Small pox / Vaccination.

  I further certify that the candidate has affixed his signature below in my presence.

  Signature of the Candidate

  Or thumb impression....................
PERSONNEL DESCRIPTION OF APPLICANT
1) Height            cms
2) Weight            kgs
3) Complexion
4) Colour of hair
5) Colour of eyes
1.
6) Personal Marks
2.

  Signature:
Station:
Name:
Date:
   Designation:

Note: The above certificate shall be issued by a Registered Medical practitioner of atleast M.B.B.S. qualification of a
civil Medical Officer of rank not lower than a Assistant Civil Surgeon.
 (Annexure - 2)
Format of practical experience certificate / service certificate and
Testimonials of good character with age from the employer
(To be issued on the letter head of the concerned mill/factory/workshop)

SERVICE / EXPERIENCE CERTIFICATE

This is to certify that Sri KUKKALA THIRUPATHAIAH aged 26 S/o K ANJANEYULU is working in our
organization as a fireman / asst fireman / operator / asst operator / boiler attendant from
.......................................................... to .......................................................... The specification of the boiler / boilers
on which the candidate is working / has worked as follows:
Sl.No. Specifications Boiler 1 Boiler 2 Boiler 3 Boiler 4
Registration No.
1.
of Boiler
Type of
2.
Boiler
Validity of
3. Boiler
Certificate
Working
4. Pressure
(Kg/Cm2)
Heating Surface
5.
(M2)
He bears good conduct and character. This certificate is issued to Sri KUKKALA THIRUPATHAIAH appears for
SECOND CLASS boiler attendant examination. The age of the candidate as per record is 26

Signature:   Counter Signature:

Name & Seal: Name & Seal:

(Under whom (Owner or agent
candidate is of mill / Factory
employed) or workshop)

Contact No: Contact No: 

Email address: Email address:

Place: Place:   

Date: Date:   

Check List and required documents to be enclosed for Boiler Attendant SECOND CLASS Application
* Filled Application with affixed photograph, Part - I, Part - II, Part - III
* Signed Part-IV
* Physical Fitness Certificate in Format Annexure - I
* Practical Experience Certificate in Format Annexure - II
* Copy of Aadhaar
* Two (2) Passport size photos
* In case of experience other than Telangana State No Objection certificate(NOC) from that State Boiler Department
to be enclosed