App.

No:4784
SUPPLEMENTARY APPLICATION FORM
18th NATIONAL CERTIFICATION EXAMINATION FOR
ENERGY MANAGERS AND ENERGY AUDITORS ­ September­2017
( Under the Energy Conservation Act, 2001 )

Examination for which you have Registered already: Energy Auditor

Registration No: EA­23195

Signature of the Candidate:

______________________________

For Office Use Only

Remarks if any
Affix a recent
_______________________________________________________ passport size photo

Controller of Examination

Exam Fee Particulars : ( DD should be in favour of "Bureau of Energy Efficiency" payable at

'Chennai')
Amount : Rs. 1500 Bank Name,Place : SBI
DD No : 037995 Date : 20/6/2017

Caption: Mr.
1. Name of the Applicant: DILIP KUMAR CHAUDHARY
2. Father's Name: R.K.CHAUDHARY
3. Present Address: 4. Permanent Address
Qr.No.­C­63/B(OLD)
MTPS OFFICERS
COLONY
MTPS
City: BANKURA City:
PinCode: 722183 PinCode:
State: WestBengal State: ­­­­­­

5. Date of Birth: 25/9/1985 6. Nationality: Indian

7. Community: General 8. Sex: Male

9. Employment Status: Employed ­ Others

10. Present Company Address:

Designation: EXECUTIVE ENGINEER
Company Name: DAMODAR VALLEY CORPORATION
MTPS BANKURA
City: BANKURA
PinCode: 722183
State: WestBengal
11. Total Work Experience: 6 Yrs Months
12. Contact Telephone. Fax, Email: Mobile: 9748224393
Office Phone: Fax:
Res. Phone: Email: dlpme2005@yahoo.co.in
Papers Appearing ­­ ­ ­­ ­ ­­­ Paper IV
13.Examination Centre:

a) Written Examination Centre: 1.Kolkata 2. Ranchi 3. Patna

14. Requisite Educational Qualification

Name of
Year of
Slno Degree/ Subjects/ Branch Board / University
Passing
Diploma
MECHANICAL
1 B.TECH 2009 UTTAR PRADESH TECHNICAL UNIVERSITY
ENGINEERING

15. Requisite Experience for fulfilling the eligibility criteria

Name of Employer/ Year

Slno Designation Nature of Work
Organisation From To
DAMODAR VALLEY ASSISTANT MECHANICAL OPERATION IN
1 21/6/2011 20/6/2014
CORPORATION ENGINEER POWER PLANT
DAMODAR VALLEY EXECUTIVE MECHANICAL OPERATION IN
2 21/6/2014 21/6/2017
CORPORATION ENGINEER POWER PLANT

Kindly write legibly your Name and Father's Name in Hindi for issuing Final Certificate in bilingual after taking
print out of the application

Name:(in Hindi)_____________________________

Father's Name:(in Hindi)_____________________________

Declaration by the Candidate

I hereby declare that all the information given in the application form and enclosures are true to the best of
my knowledge. I agree to the condition that if any information or any statement is found to be incorrect, my
registration to the examination would be cancelled. I also understand that it is my responsibility to cross
check information from the websites as mentioned in the prospectus for the allotted examination centre and
issue of hall ticket. I shall inform NPC Chennai about any change in my mailing address, telephone number
and e­mail ID, if any, at the earliest. I also abide by the examination scheme and conditions as mentioned in
the prospectus.

Place: MTPS Signature

­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­
Date: 20/6/2017 Name DILIP KUMAR CHAUDHARY

Note:
(i) Application Form received with incomplete particulars will be rejected
(ii) Allotment of Registration Number and Issue of Hall Ticket are subject to receipt of this form duly
signed by the applicant along with required documents and Demand Draft on or before the last date at the
Office of the Deputy Director General & Controller of Examination, National Productivity Council,
Dr.Ambedkar Institute of Productivity,6, Aavin Dairy Road, Ambattur Industrial Estate(North), Ambattur,
Chennai­600098

List of Enclosures to be attached with

Please tick
the Application:
1 DD* for Exam fee in favor of Bureau of
Energy Efficiency payable at Chennai. *
2 Affix one recent passport size photograph
in printed application form.
3 Proof of SC/ST/OBC certificates as per
Govt. of India format in case of claiming
fee concession. *
4 Proof of Income certificate from the
employer for self sponsored candidates in
the category of OBC having annual income
not more than Rs. 4.5 Lakh/Annum*

* These enclosures are a MUST for

Registration
Version­2017