Annexure-I RAILWAY RECRUITMENT CELL/SOUTH EAST CENTRAL RAILWAY/BILASPUR-495004 Application for Recruitment in Pay Band-I of ` 5200-20200/- + GP ` 1800/- in South

East Central Railway Employment Notice Number - SECR/03/2012 Name of the 1 Candidate ( In capital letters) Father's/Husband 2 Name ( In capital letters ) 3 Date Of Birth (DD/MM/YYYY) 4 Community(Put ) SC Date ST Month OBC Year UR Paste(do not pin or staple) here your recent colour passport size photo of size 4cm x 5 cm(The photograph shall not be more than three months old) For Office use only:

a)If OBC please state whether belonging to minority Community(Yes/No) b) If minority, indicate community 5 Are you physically disabled ( Put ) 6 Are you Ex-Servicemen (Put ) 7 Address for Communication : 8. Nationality 9. Religion 10.Sex (Put) 11 Marital Status(Put) Male Female VH Yes HH No OH Signature of the Applicant

Married Unmarried

State_____________________________________ 12 Nearest Railway Station ( In English) 13 Visible Marks of Identification : (Moles , Cuts etc.) 1 2

PIN ____________________________

14 Do you seek age relaxation under any of the category mention below? ( Put Tick in the appropriate box) : Ex- Servicemen Railway Employee Course Completed Judically separated/ Divorced Physically SC ST OBC Act Apprentice Disabled Women/ Widow

J&K Residence

15 Educational Qualifications (Tick in the appropriate column) SSLC/Matric HSC/Inter ITI/Apprentice Other Higher Qualifications

16 List of documents enclosed (Fill in the details of the copies of documents/ certificates enclosed) : 1 2 3 4 5 18 Declaration by the Candidate (Copy the passage in the box below in your own handwriting failing which application will be rejected) : I hereby declare that all the particulars given in this application are true and correct to the best of my knowledge and belief. In the event of any information being found false, my candidature/appointment is liable to be cancelled/terminated. 17. Details of IPO/Demand Draft enclosed with the application: Name of the Post Serial Number & Date Amount in ` Office/Bank

Place:

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Signature of the Applicant