Railway Recruitment Cell

Eastern Railway / 56, C.R. Avenue / Kolkata-700 012 Application Form

Employment Notice No.0113 1. Name of the candidate
Read the guidelines carefully before you start filling up the application Form

Annexure - XI For Office use

2. Fathers/ Husbands Name 3. Nearest Railway Station 4. Address for Correspondence :5. Sex 6. Nationality 7. Religion 8. Marital status 10. Persons with Disabilities
year 11. Ex-Serviceman 1st 14. Order of preference (Post code upto 5 preference)
Technical
Graduate Post Graduate

Name :Address:-

Please paste (not older than one month recent Passport size (4.5 X 3.5 cm) Photograph Without cap & colour glass

State
Contact Number with STD code
9. Date of Birth : Date Month

PIN

12. Community

13. Age Relaxation ) the appropriate column

Non Technical
Graduate Post Graduate

2nd

3rd

4th

5th

15. Educational qualification tick (

SSLC/ Matric HSC / SSC ITI

Diploma

16 Serving Employee
17. If Yes, indicate the organisation 18. Fee Exemption 19. Choice of Language for Examination

20. Personal marks of identification

1: Date : 3. Specimen signature (in full) Amount: Left Thumb Impression

2: 21. Details of IPO/DD No. Name of the Post Office / Bank & Place 1. Specimen signature (in full) 2. Specimen signature (in full)

DECLARATION BY THE CANDIDATE 22. I hereby declare that all the particulars given above by me are true, complete and correct to the best of my knowledge and belief. I am aware that in the event of any information furnished by me is found false / incorrect at any stage my candidature / service will be rejected / terminated summarily and I am also liable for criminal action. I will abide by the instructions given in the notification. (Please write above paragraph in the space given below in your own running hand writing)

Place : Date : Date :

Full Signature of the candidate (in Running Script only)