Railway Recruitment Cell

South Western Railway, Hubli

Application Form for posts in PB-I Grade Pay-Rs.1800/-(erstwhile Group 'D') in SWR (Read the guidelines carefully, before you start filling up the Application Form)
Employment Notification No.02/2013 1.Name of the candidate ( Name in CAPITAL letters as appearing in SSLC Certificate ) 2. Father's/Husband's Name 3.Nearest Railway Station

For Office Use

5. Community Tick() the appropriate column 4.Date of Birth: Date Month Year UR OBC SC ST

6.Address for Correspondence(write in CAPITAL letters)

7.Sex 8.Nationality 9.Religion 10.Marita l status Please paste(not older than one month) recent Passport size (4.5 X 3.5cm) Photograph Without cap & colour glasses

State: Contact Phone Number with STD code 11.Educational Qualification Tick() SSLC/ Matric HSC/PUC

PIN Code

the appropriate column ITI Diploma Non Technical Graduate PG Technical Graduate PG

12. Tick() the appropriate column, if applicable (Enclose copy of certificate in support of claim) Persons with Disabilities VH HH OH Widow/ Divorced/ Judicially separated women Course completed Act Apprentice Serving Employee Central/ State Govt. Employees Staff of Quasi Administrative office of Railways Residents of Jammu & Kashmir Exservicemen

13. Are you seeking fees exemption tick() appropriate box: SC ST Minority Female Ex-servicemen Persons with Disability
14.Personal marks of Identification (Scars, moles,or another permanent marks on the body ) 15.Details of IPO: No:

Economically Backward Class

1. 2.
Dt: Amount:

Name of the Post Office & place 16.List of enclosures 1. 2. 3. 4.

17.DELCARATION BY THE CANDIDATE(Please erproducethe below paragraph in your own running handwriting. NOT in capital letters) I hereby declare that all the particulars given above by me are true, complete and correct to the best of my knowledge and belief. In the event of any information furnished by me being found false/incorrect, my candidature is liable to be rejected/terminated summarily. I will abide by the instructions given in the notification.

Place:

Left Hand Thumb impression(Must be clear and not smudged) 1 2

Date:

Signature of the Candiate (Do not sign in the capital letters)