REGIONAL LABOUR INSTITUTE - DGFASLI

GOVERNMENT OF INDIA,
MINISTRY OF LABOUR & EMPLOYMENT
REGIONAL LABOUR INSTITUTE
Directorate General Factory Advice Service & Labour Institutes
Vyavsayik Swasthaya Aur Suraksha Bhawan,
SARVODAYA NAGAR, KANPUR - 208 005
APPLICATION FORM FOR ADMISSION TO
POST DIPLOMA COURSE IN INDUSTRIAL SAFETY
(Academic Session- 2013-14)
Last date for accepting duly filled-in application forms by The Head of Office, Regional Labour
Institute, Sarvodaya Nagar Kanpur-208 005, is 10 th May 2013. Application received
after this date will not be considered.
Instructions to Candidate
1. Please furnish all information in full.
2. Attach separate sheets wherever
the space provided in the form is
inadequate.
3. Attach self attested copies of
certificates & testimonials in
respect of age, qualification &
experience.
4. Before sending the filled-in
application form, please go through
the prospectus & ensure
compliance to the checkpoints
given in the end of the form.
PHOTOGRAPH
1. Name in full
(In capital letters & as per High
School or equivalent certificate)
2. Father’s Name
3. Date of Birth
4. Place of Posting in the present
Job.
(Attach a certificate from your present employer)
1

5. Postal Address
(For correspondence)
6. Address of employer
(Sponsoring / Permitting authority)
Pin Code:
Telephone Numbers with STD code:
Residence:
Office:
Mobile No:
Email:
Pin code:
Office phone no. with STD code:
Fax No with STD code:
Mobile No:
Email :
7. Permanent Address
Pin Code:
Telephone No. with STD code :
Mobile No:
8. Are you a member of SC/ST/Ex-
Army/OBC/NT/VJ?
If so give particulars
(Attach self attested certificate issued
within six month by competent
authority)
2

9. Details of Academic Qualifications.
(High School, S.S.C or equivalent & onwards examinations passed. Attach self attested copies of all the
certificates and mark sheets)
Sr.
No,
Name of
Examination Passed
Name and Address
of
School,
College/Institute
University
/ Board
Date &
Year of
Passing
Class/Div
ision
Obtained
Mark’s
Obtained
with
Percentage
1 2 3 4 5 6 7 8
Subjects
10. Details of experience (in chronological order). Attach self attested copies of the certificates.
Sr
No.
Name and Address of
Organisation where
employed (starting from first
employment & ending with
present employment)
Designation
and
pay
Employment Period
Give exact dates
From
To
Employment
Duration
Indicating Years,
months and days
Nature of Duties
(Enclose self
attested copies of
the certificates )
1 2 3 4 5 6
11.Total experience (From first employment up to 30 June 2013):……….Year ……Months……..days
12. Give the details , if you have earlier applied at this institute for this course.?
13. Any other information which the applicant desires to give in support of his candidature.:
3

14. Hostel accommodation: Required / Not required (Women hostel is not available)
15. Declaration by the candidate
I hereby declare that information furnished in the application is true and correct to the best
of my knowledge and belief and that no material information has been willfully suppressed by me.
If at any stage it is found that I do not fulfill the eligibility requirements, have used fraudulent
means to secure admission, have made false or incorrect statements or my qualifying examination
is not recognised by the Board of Technical Education, U.P, then I shall not be allowed to appear
at the interview, complete admission formalities, or if in any case already admitted, my admission
shall be cancelled and my application/certificates/documents and the fee paid shall not be
returned. I also undertake that after my admission to the course. I shall complete the requisite
attendance, projects and term work during the period of the course.
Date:
Place:
Signature of the candidate
CERTIFICATE BY SPONSORING/ PERMITTING AUTHORITY
(Either ‘A’ or ‘B’ of the formats given below should necessarily be completed by the employer of the
organisation where the candidate is employed and which is sponsoring or permitting the candidate for this course)
( A) CERTIFICATE FOR SPONSORED CANDIDATE
Shri ……………………………………………. holding the post of------------------------------- --------- in this
organisation is hereby sponsored to attend the POST-DIPLOMA COURSE IN INDUSTRIAL SAFETY
during the academic year 2013-2014. The application for admission in the prescribed form, duly filled
in, has been verified and is forwarded herewith.
Shri ……………………………………………………………………………………… is working in this
organisation …………………………………….. w.e.f. ……………………………………….
Place:
Date:
……………………..
……………………..
Signature of the Sponsoring Authority,
Name, Designation & Address
Seal of Sponsoring Authority
Office Ph. no. with STD Code :
(Mobile No.) :
Fax No.:
E-mail.:
4

OR
( B) CERTIFICATE FOR PERMITTED CANDIDATE
Shri ……………………………………………. holding the post of------------------------------- --------- in this
organisation is hereby permitted to attend the POST-DIPLOMA COURSE IN INDUSTRIAL SAFETY
during the academic year 2013-2014. The application for admission in the prescribed form, duly filled
in, has been verified and is forwarded herewith.
Shri ……………………………………………………………………………………… is working in this
organisation …………………………………….. w.e.f. ……………………………………….
Place:
Date:
……………………..
……………………..
Signature of the Permitting Authority,
Name, Designation & Address
Seal of Sponsoring Authority
Office Ph. no. with STD Code :
(Mobile No.) :
Fax No.:
E-mail.:
CHECKLIST
(Please ensure the followings before sending your application form)
1. Whether you have written your name in the application form in the same manner as is shown in your High School or equivalent
certificate?
2. Since only those who are presently employed & possess requisite qualification & experience are eligible to apply, please check
whether your employer, sponsoring you to do this course, has signed your application form along with his legible seal & full
address? If not, then a certificate from your present employer clearly mentioning that you are permitted to do this course should
be enclosed.
3. Whether you have enclosed self attested copies of your high school certificate & degree / diploma certificates along with their
mark sheets as well as experience certificates (showing the duration & nature of the experience)?
4. Whether original certificates of high school, degree / diploma are in your safe custody? These will have to be produced before
admission. Admission will not be given based upon the provisional certificates.
5. Whether you have enclosed equivalence certificate for the basic minimum qualification required for the course? (This is
ughter
necessary only for those candidates who claim that the examination passed by them is equivalent to the basic minimum
qualification.)
6. Whether you have signed in your application form?
******
*******
5

(HINDI VERSION)
Hkkjr ljdkj]
Je ,oa jkstxkj ea=ky;
{ks=h; Je laLFkku dkuiqj
(dkj[kkuk lykg lsok vkSj Je laLFkku egkfuns'kky;)
O;kolkf;d LokLF; vkSj lqj{kk Hkou]
loksZn; uxj] dkuiqj & 208 005
'kS{kf.kd o"kZ 2013&2014
vkS|ksfxd lqj{kk ds iksLV fMIyksek ikB~;dze esa izos'k ds fy, vkosnu i=
iw.kZ #Ik ls Hkjk vkosnu i= bl izdkj Hkstsa fd og dk;kZy;k/;{k] {ks=h; Je laLFkku] loksZn; uxj] dkuiqj
&208 005 dks 10 ebZ 2013 rd izkIr gks tk, A nsjh ls izkIr vkosnu i=kas ij fopkj ugh fd;k tk,xkA
izkfFkZ;ksa dks vuqns'k
1- d`i;k lHkh lwpuk;sa iw.kZ:i esa nsaA
2- izi= esa fn;k x;k LFkku ;fn vi;kZIr gks rks vyx ls 'khV yxk;sa A
3- vk;q] ;ksX;rk ,oa vuqHko ds laca/k esa Lo % izekf.kr izek.k i= ,oa vU; nLrkostksa dh izfr;ka layXu djsaA
4- izi= Hkstus ls igys fooj.k if=dk dk v/;;u dj ysa rFkk izi= ds var esa fn, x, tkap
fcUnqvksa dk ikyu lqfuf'pr dj ysaA
QksVks
1- iwjk uke
(cM+s v{kjksa esa rFkk gkbZ Ldwy vFkok
led{k izek.k i= ds vuqlkj)
2- firk dk uke
3- tUe frfFk
4- orZeku lsok esa fu;qfDr dk LFkku
(bl lanHkZ esa vius fu;std dk izek.k i=
layXu djsa )
6

5- Mkd irk (i= O;ogkj ds fy,)
6- fu;ksDrk dk irk
(izk;kstd@vkKk iznkrk vf/kdkjh)
fiudksM%
VsfyQksu ua0 ,l-Vh-Mh- dksM ds lkFk%
vkokl%
dk;kZy; %
Ekskckby ua0%
bZ&esy %
fiudksM%
dk;kZy; dk VsfyQksu ua0 ,l-Vh-Mh- dksM lfgr%
QSDl ua0 ,l-Vh-Mh- dksM lfgr %
Ekskckby ua0%
bZ esy %
7- LFkk;h irk
fiudksM%
VsfyQksu ua0 ,l-Vh-Mh- dksM lfgr%
Ekskckby ua0%
8- D;k vki vuqlwfpr
tkfr@tutkfr@HkwriwoZ lSfud@
vks0ch0lh0@,u0Vh0@oh0ts0
ds lnL; gSaA
;fn gk¡] rks fooj.k nsa rFkk l{ke vf/kdkjh
}kjk 6ekg ds Hkhrj fuxZr fd;k x;k
Loizekf.kr izek.k&i= layXu djsaA
7

9- 'kSf{kd fooj.k
gkbZ Ldwy@,l-,l-lh- ijh{kk vFkok led{k vkSj mlds ckn dh ijh{kkvksa ds izek.ki=ksa ,oa vadrkfydkvksa dh Loizekf.kr izfr;k¡ layXu
djsaA
Ø-
LA-
ijh{kk tks mRrh.kZ dh
Ldwy] dkyst@ laLFkk
dk uke ,oa irk
fo'ofo|ky;@cksMZ
mRrh.kZ
djus dh
frfFk ,oa
o"kZ
izkIr
Dykl@Js.kh
IzkIrkadksa dk
izfr'kr
fo"k;
1 2 3 4 5 6 7 8
10- vuqHko dk fooj.k (dzekuqlkj)A izek.ki=ksa dh Lokizekf.kr izfr;ka layXu djsa A
Ø-
la-
laxBu dk uke ,oa irk tgka ij izfrHkkxh dk;Zjr
gS (izFke jkstxkj ls 'kq# djrs gq, orZeku jkstxkj
rd)
in ,oa osru
vof/k
frfFk;ksa lfgr
dqy dk;Zkof/k
o"kZ] eghukas ,oa
fnuks esa
dk;Z dh izo`fRr
(nLrkostksa dh Loizekf.kr
izfr;ka layXu djsa)
ls rd
1 2 3 4 5 8
11- dqy vuqHko (izFke jkstxkj ls 30 twu 2013 rd) -------- ----o"kZ --------------ekg --------------- fnu
12- D;k vkius blds iwoZ laLFkku esa dHkh bl ikB~;dze ds fy, vkosnu fd;k gS ?
% fooj.k ns
13- vU; dksbZ lwpuk tks fd mEehnokj viuh
mEehnokjh ds leFkZu esa izLrqr djuk pkgrk gSA%
14- gksLVy fuokl pkfg, vFkok ugha (laLFkku esa efgyk Nk=kokl dh lqfo/kk miyO/k ugha gSA)
8

15- izkFkhZ }kjk ?kks"k.kk
tgk¡ rd eq>s Kkr ,oa fo'okl gS bl izkFkZuk i= esa nh x;h lwpuk,a lR; vkSj Bhd gSA esjs }kjk tku&cw>dj dksbZ lwpuk
fNikbZ ugha x;h gSA ;fn fdlh Hkh Lrj ij ;g ik;k tkrk gS fd eSa okafNr ;ksX;rk,a ugha j[krk gwa ;k eSaus izos'k ikus gsrq >wBs nLrkost
;k oDrO; xyr fn, gSa ;k esjh izos'k gsrq U;wure 'kS{kf.kd ;ksX;rk izkfof/kd f'k{kk ifj"kn] m-iz- }kjk ekU; ugha gS rks eSa lk{kkRdkj ls]
nkf[kys dh vkSipkfjdrkvksa ls oafpr dj fn;k tkÅaxkA ;k vxj eq>s fdlh Hkh izdkj ls izos'k fey Hkh tkrk gS rks esjk izos'k fujLr
ekuk tk,xk vkSj esjs }kjk tek fd, x, izkFkZuk i=@izek.k i=@nLrkost o 'kqYd okil ugha fd, tk,axs A eSa izos'k gksus ij ikB~;dze
vof/k ds e/; esa vko';d mifLFkfr;k¡] izkstsDV~l ,oa VeZ odZ dks iwjk djus dh Hkh ftEesnkjh ysrk gw¡A
fnukad :
LFkku :
izkFkhZ ds gLrk{kj
izk;kssftr vFkok vuqwefr nsus okys vf/kdkjh dk izek.k i=
(fuEufyf[kr izk:i ^d* vFkok ^[k* dks fu;ksDrk }kjk vko';d :i ls Hkjk tk, ;fn laxBu }kjk mEehnokj dks izk;ksftr fd;k
x;k gks vFkok vuqefr nh xbZ gks )
(d) izk;kssftr vH;fFkZ;ksa ds fy, izek.k i=
bl laxBu ds Jh ---------------------------------------------------- --------------tks------------------------------------------- ds in ij
dk;Zjr gSa dks vkS|ksfxd lqj{kk ds iksLV fMIyksek ikB~;dze ds 'kSf{kd l= 2013&2014 esa izos'k gsrq izk;ksftr fd;k x;k gS
rFkk izos'k gsrq izkFkZuk i= fu/kkZfjr izi= esa fof/kor Hkjk gqvk ,oa lR;kfir djds vxzlkfjr fd;k tkrk gSA
Jh -------------------------------------------------------------------- bl laxBu esa fnukad ------------- --------------ls dk;Zjr gSaA
LFkku ---------------------
fnukad ---------------------
(dk;kZy; VsfyQksu ua0,l-Vh-Mh- dksM ds lkFk):
eksckby ua0:
izk;kstd vf/kdkjh dk gLrk{kj uke q]in ,oa irk
izk;kstd vf/kdkjh dh eksgj
QSDl ua-:
bZ&esy:
vFkok
9

([k) vuqwefr izkIr vH;fFkZ;ksa ds fy, izek.k i=
bl laxBu ds Jh ---------------------------------------------------- --------------tks------------------------------------------- ds in ij
dk;Zjr gSa dks vkS|ksfxd lqj{kk ds iksLV fMIyksek ikB~;dze ds 'kSf{kd l= 2013&2014 esa gsrq ikB~;Øe djus dh vuqefr
nh tkrh gS rFkk izos'k gsrq izkFkZuk i= fu/kkZfjr izi= esa fof/kor Hkjk gqvk ,oa lR;kfir djds vxzlkfjr fd;k tkrk gSA
Jh ------------------------------------------------- bl laxBu esa fnukad ----------------------- --------------ls dk;Zjr gSaA
LFkku ---------------------
vuqefr iznku djus okys vf/kdkjh dk gLrk{kj uke q]in ,oa irk
fnukad --------------------- --------------------------------------------
vuqefr iznku djus okys vf/kdkjh dh eksgj
(dk;kZy; VsfyQksu ua0,l-Vh-Mh- dksM ds lkFk):
eksckby ua0:
QSDl ua-:
bZ&esy:
tk¡p lwph
(d`i;k vkosnu i= Hkstus ls igys fuEu fcUnq lqfuf'pr dj ysa)
1- D;k vkius vkosnu i= esa viuk uke mlh izdkj fy[kk gS tSlk fd vkids gkbZLdwy vFkok led{k izek.k i= esa n'kkZ;k gqvk gS\
2- pwafd dsoy ogh O;fDr tks bl le; dk;Zjr gS rFkk okafNr 'kS{kf.kd ;ksX;rk ,oa vuqHko j[krs gSa] bl ikB~;Øe dks djus ds fy,
;ksX; gSa A blfy, ;g lqfuf'pr djsa fd vkids fu;ksDrk @izk;ksftr djus okys vf/kdkjh us viuh Li"V eksgj o irs ds lkFk
vkosnu i= ij gLrk{kj fd;s gSa ;fn ugha rks vius fu;ksDrk ls bl vk'k; dk izek.k i= layXu djsa fd og vkidks bl
ikB~;Øe dks djus dh vuqefr nsrs gSa A
3- D;k vkius gkbZLdwy vFkok led{k o okafNr fMxzh @ fMIyksek izek.k i=ksa o vadrkfydkvksa ,oa vuqHko izek.k i=ksa (vuqHko dh
vof/k o dk;Z dh izd`fr n'kkZrs gq,) dh izfr;ka Loizekf.kr dj vkosnu i= ds lkFk layXu dh gS \
4- D;k gkbZLdwy] fMxzh@fMIyksek ds ewy nLrkost vkids ikl lqjf{kr j[ks gSa \ ;g vkidks izos'k ls igys fn[kykus gksaxsA izos'k
izksfotuy izek.k i=ksa ds vk/kkj ij ugha fn;k tk,xkA
5- D;k vkius ikB~;Øe ds fy, vko';d cqfu;knh ;ksX;rk ds led{k ;ksX;rk dk izek.k&i= layXu dj fn;k gS (;g mu vH;fFkZ;ksa
ds fy, vko';d gS tks muds }kjk mRrh.kZ dh xbZ ijh{kk dks U;wure cqfu;knh ;ksX;rk ds led{k gksus dk nkok djrs gSaA)
6- D;k vkius vkosnu i= ij gLrk{kj dj fn, gSa\
********
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