FORM OF APPLICATION FOR AUTHORISATION UNDER REGULATION
34(4) & REGULATION 34(6) OF METALLIFEROUS MINES
REGULATIONS, 1961
To *****
:
The Director of Mines Safety,
DGMS Udaipur Region Paste here
Jhamar Kotra Road, Sector-6, recent passport
Udaipur - 313002.
size
photographs
Sub: Application for permission under Regulation 34(4) & Regulation 34(6)
of the Metalliferous Mines Regulations, 1961 to work as manager of
more than one mine.
Sir,
I beg to apply for manager’s authorization/renewal of authorization under Regulation
34(4) & Regulation 34(6) of the Metalliferous Mines Regulations, 1961 to work as
Manager of following mines: (give details of mines, its location etc.)
Detail Mine 1 Mine 2 Mine 3 Mine 4
s
Name of Mine
ML No./QL No.
Name of Owner as per Lease
document
(Name of all partners in case
of partnership firm)
Survey No.
Village & Post
Taluk/Mandal
District
State & Pin code
Contact No. & email address
Details of Applicant:
1. Name of the Applicant :
1a. Certificate held ( Type, Number &
Date such as Foreman, Second
Class or First Class etc.)
1b Details of last medical
examination (Name of center and
date of medical
examination & validity of
statutory certificate)
2. Father’s Name :
3. Address for correspondence :
Page 1 of
4. Contact Number & email address :
Page 2 of
5. Date of Birth :
(Enclose documentary evidence)
6. Aadhar Card Number :
(Enclose copy of Aadhar Card)
7. Were you earlier authorised to act
as Manager under Reg.34(4) of
MMR,
1961, if so
(a) Name of the mine :
(b) Location of the mine :
(c) Name of the owner :
(d) Authorisation Letter No.
& date
(e) Period from & to
8. Number of Shifts worked: : One/Two/Three.
9. Details of Statutory Supervisory staff (Photo copy of certificate to be enclosed):-
Name
Certificate No. &
Date
Validity upto
9A. Details of Non-Statutory Supervisory staff:-
Name Qualification Experience
10. A. Details of machinery deployed (Mine-1):
SN Machinery Specification HP/ Nos. Total HP
Capacity
1. Excavator
2. Dumper
3. Tipper
4. Drill Machine
5. Compressor
6. Others(specify)
10A. B. Details of machinery deployed (Mine-2):
SN Machinery Specification HP/ Nos. Total HP
Capacity
1. Excavator
2. Dumper
3. Tipper
4. Drill Machine
5. Compressor
6. Others(specify)
10B. B. Details of machinery deployed (Mine-3):
SN Machinery Specification HP/ Nos. Total HP
Capacity
1. Excavator
2. Dumper
3. Tipper
4. Drill Machine
5. Compressor
6. Others(specify)
10C. B. Details of machinery deployed (Mine-4):
SN Machinery Specification HP/ Nos. Total HP
Capacity
1. Excavator
2. Dumper
3. Tipper
4. Drill Machine
5. Compressor
6. Others(specify)
11. Permission under Reg.106(2)(b) of MMR, 1961:
Mine Mine 2 Mine 3 Mine 4
1
Whether permission was
obtained
Letter No. & Date
12. Details of Mines and owner/s such as their communication address etc. :
Detail Mine 1 Mine 2 Mine 3 Mine 4
s
Name of the Mines
i) Name of the Mine:
ii) Labour
Identification
Number(LIN) :
iii) Have you filed last
year’s Annual Return
with online “Shram
Suvidha” unified portal
(Return period from
January to December)?
if Yes, please
indicate submission Id.
:
if No, reason
thereof :
Name & address of the
owner
Contact number & email
address of owner
No. of leaseholds in the
mine property
(one/two) with validity
of lease
period
Extent of area
No. of workings
(Pits/Sections/Blocks)
Detail Mine 1 Mine 2 Mine 3 Mine 4
s
Length of the pit
Width of the pit
Depth of the pit
Manpower
deployed/ engaged
Details of Explosive
Magazine such as
licence No. and validity
(enclose a copy of
magazine)
Details of explosives
used at the mine.
Distance between
the mines
Mode of
conveyance
provided to the
manager
I request your goodself to kindly permit me to work as Manager of the above
mentioned mines.
Date:
(Name & Signature of the
Candidate)
Name & Signature of Owner/Agent, Mine No.1.
Name & Signature of Owner/Agent, Mine No.2.
Name & Signature of Owner/Agent, Mine No.3.
Name & Signature of Owner/Agent, Mine No.3.
(Name & signature of all partners in case of
partnership firm)
Note: Enclose relevant documents along with application with self attestation
by respective owner of mine.
