sina015 a a060 ELECTRICAL LICENSING BOARD OF ODISHA 3rd Floor,Heads of Dept Building, Bhubaneswar-751001 Email ld = secyebo@nic.in, Phone:-0674-2394572 Application No. ‘Name of the Applicant [Name of the Father Date OfBirth Age as on 17/10/2015 Present Address Permanent Address Gender Category Mobile No mab td QUALIFICATION DETAILS PRESENT EMPLOYEMENT DETAILS. ‘Working as DURATION OF WORK EXPERIENCE EXPERIENCE DETAILS Educational Qualification ‘Technical Qualification Name of the Offce/Firm Date of Employement Website = http:/as1 orinic.infeicelectricity ONLINE APPLICATION FOR WORKMAN(HT) PERMIT EXAMINATION 2015 WATO01730 NABGHAN BISWAL BHASKAR BISWAL 6/06/1982 33 Year(s) 6 Month(s) ‘Space for Photograph AT- Rautal Post- Bimalbeda Dist- Angul Pin-759127 Odisha AT Rautal Post- Bimalbeda Dist- Angul Pin-759127 Odisha Male General 9556707703 biswaXh606@gmaileom 1012 IT1Ekeetrician) Bketrician + JaiMaa Hingula Electricals 2010772011 (Designation) HT Works + 4 Year(s) and 4 Month(s) SI ne From Date Organization To Date Posting Contractor [Designation| licence Description ‘Superviser| Licence lai Maa Hingula fetectrzals 2007/2011 B1/122015 [Ekeetrician [Up To 11 KV ‘Angl = (2363(HT) 299s(H) LINEMAN MY PERMIT DETAILS OF THE APPLICANT Category ofeence issued Issuing Authority = Lineman-C SE-Cum-EL Angul BBS/AGL/2110 01/01/1900 11/09/2017 Licence No. Date of Issue Valid Period + ‘TREASURY CHALLAN DETAILS Challan No Amount 0043/13418 200.00 wesuna015 Date : 24/12/2015 ‘Name of the Treasury : Angul Dist Treasury CHOICE OF CENTER First Choice ANUGUL. Second Choice: DHENKANAL Third Choice DHENKANAL. UPLOADED DETAILS Experience certificate as per the format : Yes ‘Treasury Challan and Caste Certificate as necessary : Yes Photo & Signature : Yes DECLARATION Thereby declared that the particulars stated above are correct and true to the best of knowledge and belief. If the information being found false or incorrect my $.C.C. is to be cancelled. Phe Date Full Signature ofthe Applicant