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ELECTRICAL LICENSING BOARD OF ODISHA FORM A Regulation 15 APPLICATION FOR ELECTRICAL WORKMAN PERMIT ON EXEMPTION BASIS FOR THE CATEGORY WIREMAN MV / LINEMAN MV STRIKE OUT WHICH EVER IS NOT APPLICABLE 1. Full name of the applicant in block letters Paste recent Passport size Colour Photograph 2. Name of the father 3. Present address 4. Permanent address 5. Date of Birth Day Month Year 6. Age as on date of Application yrs 7. Gender M / F 8. Mobile no 9. Details of qualification a Educational b Technical c Name of the Institution 10. Whether employed Yes No 11. Name of the employer if employed 12. E challan no / date Amount 13. Name of the Treasury Contd P/2 // 2 // Declaration All the information given above by me is correct to the best of my knowledge and belief* If the information being found false or incorrect my permit is to be cancelled* Date Full Signature of the Applicant Specimen Signature CERTIFICATE ABOUT CONDUCT AND CHARACTER To be given by Gazetted Officer I certify that Shri. is personally known to me the last. Years and to the best of my knowledge and belief bears a good moral conduct and moral character. Signed at Place Date. D t Si t ith S l Signature with Seal Name and address to be legibly written Mobile No The following documents to be enclosed with the application Tick the appropriate boxes a Xerox copy of Educational qualification with self attestation b Xerox copy of Technical qualification with self attestation c Xerox copy of proof of date of birth with self attestation Licenses/ Aadhar Card / Passport with self attestation e Xerox copy of address proof such as Telephone Bill / Electricity Bill / Bank Pass Book / GAS Card LPG / any other proof in support of address with self attestation f 3 Three nos. of recent passport size colour photograph with white background g Original E channal in support of payment of the application fees of Rs. 150/ Rupees one hundred fifty only non refundable for the examination* The said amount is to be deposited through E challan in the head of account no 0043 00 102 0034 01001 000. Full name of the applicant in block letters Paste recent Passport size Colour Photograph 2. Name of the father 3. Present address 4. Permanent address 5. Date of Birth Day Month Year 6. Age as on date of Application yrs 7. Present address 4. Permanent address 5. Date of Birth Day Month Year 6. Age as on date of Application yrs 7. Gender M / F 8. Mobile no 9. Details of qualification a Educational b Technical c Name of the Institution 10. Gender M / F 8. Mobile no 9. Details of qualification a Educational b Technical c Name of the Institution 10. Whether employed Yes No 11. Name of the employer if employed 12. E challan no / date Amount 13. Name of the Treasury Contd P/2 // 2 // Declaration All the information given above by me is correct to the best of my knowledge and belief* If the information being found false or incorrect my permit is to be cancelled* Date Full Signature of the Applicant Specimen Signature CERTIFICATE ABOUT CONDUCT AND CHARACTER To be given by Gazetted Officer I certify that Shri.

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