Certificate of proficiency examinations

Ministry of Communications & Information Technology

Wireless Planning & Coordination Wing
FORM OF APPLICATION FOR ADMISSION TO EXAMINATION FOR AWARD OF Global Maritime Distress & Safety System (GMDSS) GENERAL OPERATOR’S(GOC) CERTIFICATE
1. Name of Applicant (in Block letters) :
2. Father’s Name :

1. 
   Full Postal Address for communication :
   

4. Marks of Identification :

5. Date of Birth (Attach an attested copy of :

School Leaving Certificate or Matriculation Certificate)

6. a) Are you a citizen of India by Birth and /or Domicile :

b) If not, to which country you belong (attach attested copy of Passport) :

7. Whether copy of requisite Qualification Cerificate attached:

(i) 10+2 certificate : No. Date

OR

(ii)COP/COC/COS: No. Date of expiry:

8. ( i ) Demand Drafts Number/Date/Amount :

(ii) Issue Branch with Code No. :

DECLARATION

I hereby solemnly declare that the foregoing facts are true and correct and nothing is false therein and nothing material has been concealed therefrom. I also agree that in case any information given by me herein before is found false at later date, the certificate and licence to operate, if granted, will be cancelled.

I also certify that I shall maintain Secrecy of correspondence as required under the Rules.

Place: Signature of the applicant
Date: Name (in Block letters)

1. 
   Certified that the particulars furnished by the candidate above are true to the best of my knowledge and behalf.
   
2. 
   Certified that the candidate above has undergone/has not undergone prescribed training.
   

Date: (PRINCIPAL)

2

FOR OFFICE USE ONLY

Roll Number allotted :

Centre : NEW DELHI

Date of Examination :
Marks obtained : Part I ………………..
Part II ……………….

Result : Passed/Failed

(Witness Signature) Signature of Examination-in-Charge

Certificate/Licence Number Issued

Validity of Certificate/Licence

Signature of AWA to Govt. of India

3
ATTENDANCE SHEET CUM RESULT SHEET
GMDSS GOC LICENCE NO.:

PHOTOGRAPH DATE OF ISSUE :

AWA TO GOI
1. NAME: (a) in Hindi: (b) in English:
2. FATHER’S NAME (In Eng) :
3. DATE OF BIRTH :
4. PLACE OF BIRTH :
5. NATIONALITY :
6 (a) HEIGHT (In Cms) ______ (b) COLOUR OF EYES ____________ (c) COLOUR OF HAIR________________ (d) COMPLEXION________________
7. MARKS OF IDENTIFICATION: ________________________________
8. QUALIFICATION: (a) 10+2:

(i) Certificate No.: _________________ Dated: _____________

(ii) Marks Shee No: _________________

(b) IN CASE OF COC, COP, COS Licence No. _________________valid till: ____________

9. PERMANENT ADDRESS ___________________________________________________

(WITH PIN CODE) ___________________________________________________

10. CONTACT TEL. NO./E-MAIL : ___________________________________________

CENTRE : ROLL NO.:

Signature of the candidate Date : Marks Result Signature of the Examiner : Exam-I-C/Examiner

PART:I (Written) :

PART: II (Sec.A) :

(Commercial Wkg.) :

PART: II Practical :

Examiner DGS :

Examiner, WPC :

Exam.-in-Charge :

Prov. GOC. Lic. No.--------------------------------- Issued on:---------------------------------------

Note: Staple two identical colour photographs with name, on reverse side with this form and paste one above. Necessary undertaking wherever necessary must be attached by provisionally admitted candidates.
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DECLARATION

I hereby solemnly declare that the foregoing facts are true and correct and nothing is false therein and nothing has been concealed therefrom. I also agree that in case any information given by me herein before is found false at a later date, the certificate and licence to operate, if granted, will be cancelled.

I also certify that I shall maintain secrecy of correspondence as required under the Rules.

Place Signature of the Applicant

Date Name

(in block letters)

1. Certified that the particulars furnished by the candidate Shri__________________________________ above are true to the best of my knowledge and belief.
2. Certified that the candidate has undergone prescribed training from ________ to _________.

Signature (…………………………….)

Name

Place: Chief Course Coordinator GMDSS

Name of the Institute

Date: Stamp of the Institute :

FOR FOREIGN NATIONALS

PERSONAL PARATICULARS OF APPLICANT

(To be submitted in six copies)
1. (a) SURNAME : NATIONALITY :

(b) NAME: PLACE OF BIRTH:

2. DATE OF BIRTH:
3. FATHER’S NAME:
4 (a) PRESENT FULL ADDRESS : PERMANENT ADDRESS :

(IN INDIA)
CITY : CITY :

STATE : STATE :

5 (a) PASSPORT NO: DATE: VALID UPTO:
(b) VISA NO. : DATE: VALID UPTO:


6. PURPOSE & PERIOD OF STAY IN INDIA:

Alongwith Full Address

7.(a) DO YOU BELONG TO DEFENCE FORCES :

OF YOUR COUNTRY?
8. ANY OTHER INFORMATION :

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 is found false at a later, the certificate and licence to operate, if granted, will be cancelled.

Name & Signature of Applicant

Place :

Dated :

Form of application for Renewal of

COP Licence
(Radio Telegraphy/Telephony

In

Aeronautical/Maritime Services)

C.O.P.- 23