Annexure I-A
FORM OF APPLICATION FOR ISSUE OF CERTIFICATE OF PROFICIENCY IN
RADIO TELEPHONE AND LICENCE TO OPERATE
1.
(a)Name of Applicant
BLOCK LETTERS.
(b) In Hindi (if possible.)
2.
(a) Name of Examination centre.
(b) Month of Exam.
3.
Complete postal address
Where licence to be sent.
4
Fathers name.
:
5.
Date of birth.
:
6.
Place of birth.
:
7.
Nationality.
:
8.
Height. (a) Mtrs.
Cms.
9.
Colour of Eyes:
9.Colour of Hair.
10. Complexion.
11.Marks of identification.
:
12.Type of licence applied for:
(a) 20 years.
(b)
Life Time.
(Tick wherever applicable)
13.Details of DD enclosed :-( DD should be drawn as mentioned in the result
notification / memorandum
(a) Drawn in favour of:
(b)
DD Amount.
(c) DD No.
(d) Date.
(For 20 years Licence fee is Rs. 5, 000/- and for Life time Rs: 10, 000/-)
DECLARATION
1.
I hereby solemnly declare that the foregoing facts are true and correct and nothing is false
therein and nothing material has been concealed there from.
I also agree that in case any
information given by me herein before is found false at later date, the certificate and licence to
