Annexure I-A

FORM OF APPLICATION FOR ISSUE OF CERTIFICATE OF PROFICIENCY IN RADIO TELEPHONE AND LICENCE TO OPERATE 1. (a) Name of Applicant BLOCK LETTERS. (b) In Hindi (if possible.) : 2. (a) Name of Examination centre: MUMBAI (b) Month of Exam. : MAR 2012 3. Complete postal address: COMBAT ARMY AVN TRG SCHOOL Where license to be sent. GANDHINAGAR AIRPORT, NASIK ROAD
CAMP, NASIK-422006(MAHARASHTRA) PRATAP SINGH

Paste a recent Passport size Photograph

4 Fathers name. : SHRI KRISHAN PRATAP NARAYAN SINGH 5. Date of birth. : 11 DEC 1971 6. Place of birth. : GORAKHPUR (UTTAR PRADESH) 7. Nationality. : INDIAN 8. Height. (a) Mtrs. 1 (b) Cms. 73 9. Colour of Eyes: BROWN 9.Colour of Hair: BLACK 10. Complexion: WHEATISH 11. Marks of identification. : SCAR OVER LEFT EYE LID 12. Type of licence applied for: (a) 20 years. (b) Life Time. (Tick wherever applicable) 13. Details of DD enclosed :-( DD should be drawn as mentioned in the result notification / memorandum (a) Drawn in favour of: Communication Accounts Officer (Cash), CCA, MUMBAI (b) DD Amount. Rs 10000/- (c) DD No. (d) Date. (For 20 years Licence fee is Rs. 5, 000/- and for Life time Rs: 10, 000/-) DECLARATION 1. 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 herein before is found false at later date, the certificate and licence to operate, if granted will be cancelled. 2. I further solemnly give an undertaking that I will not either directly or indirectly divulge to any person, except when lawfully authorized or directed to do so, the purport or any message which I may transmit or receive by means of any wireless apparatus operated by me or which may come to my knowledge in connection with the operation of the said apparatus. 3. I have carefully read and understood the rules contained in the Indian Wireless Telegraphy (Commercial Radio Operators Certificates of Proficiency and licence to operate Wireless Telegraphy) Rules, 1954 and undertake to abide by them.

Date: 02 MAY 2012 Signature of applicant Place: NASIK (PRATAP SINGH) Note: Enclose:1. An identical passport size photograph in an envelope. 2. A self addressed (Unstamped) envelope of good quality size 27X12 Cms. 3. DD as mentioned above.

UNDERTAKING I, Pratap Singh, S/o Shri Krishan Pratap Narayan Singh, hereby undertake to state that I am not in possession of any RTR Permits issued by WPC, MOC & IT based upon Foreign FRTOL. Hence I may be issued RTR license based upon the result of RTR (A) examination held at Mumbai vide my roll no 1.

Signed at Nasik on 02 May 2012 In presence of

Name: Address:

Lt Col Simerpreet Singh Cheema Cdr Flg & Grnd Trg Wing Combat Army Aviation Training School Gandhinagar Airport Nasik Road Nasik - 422006

(Pratap Singh)