Panchayat:Repo18/vol1-page0840

APPENDIX K

[See Rule 141 (1)]

Application for Registration as Architect/Engineer/Town Planner/Supervisor etc. under the Kerala Panchayat Building Rules, 2011


Affix Passport size photo

(One extra copy of the photo should be separately enclosed

for issuing identity card)

Name of Applicant in capital letters :

Permanent Address :

Address to which communications

are to be sent :

Educational Qualifications

(Attested copies should be enclosed) :

Age and Date of Birth (with proof) :

Sex :

Experience (Attested copies should

be enclosed) :

References of previous licences, if any :

Details of show cause notices received/

cancellation of licences, if any :

Whether employed or not

(If employed Give particulars) :

Whether retired from service or not

(If Retired, give details proof to be attached):

Specimen Signature :

(i)

(ii)

(iii)

Declaration.

I, …………… hereby declare that the details furnished above are correct, complete and true to the best of my knowledge and belief.

Signature:

Name:

Place:

Date: