.

22 ()

 SOUTHERN RAILWAY

G.22 (Revised)

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APPLICAATION FOR PRIVILEGE PASS/PRIVILEGE TICKET ORDER

    "# "#
/ ' /  + /
 .  . 1 /  '
"# 3 "# . 3 6 3 7

I hereby apply for single/return journey Privilege Pass/P.T.O. as below subject to the Railways
regulations and conditions relating to Privilege Pass/P.T.O. and declare that it is/they are for the use of the
person/persons mentioned below and I hereby agree to indemnify the Railways over whose lines the same
is/are available against any claims made upon them by, or on behalf of any person using such Pass/P.T.O.

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Description of Persons shown by tick () for whom Pass/P.T.O. Tickets are required

9
Age

12    Full tickets All over 12 years

5  12  &

Half tickets. All over 5 and under 12 years.
(1)

(2)
(3)
(4)
(5)

(6)
(7)
(8)
(9)

:/Self
=//Wife/Husband
> >, /Mother or Step-mother , widowed
 , / Sisters or step-sisters, unmarried/widowed
' ' = ', //18 D

 CERTIFICATE
R 1 + . U / /  /
N W /R / R Y / 
Z
I certify that the relatives for whom Privilege Pass/PTO are required is/are residing with and wholly
dependent upon me and no brother of mine is obtaining Privilege Pass/PTO for this relative.
Z /MY FATHER IS NOT ALIVE

# :. . . . . .. . . . . . . . . . . . . . . .
Station employed at
. . . . . . .. . . . . . . . . . . . . . . .. . . . . .
Date

:6. . . . .. . . . . . . . . . . . . . . .. . . .
Signature of applicant
. . . . .. . . . . . . . . . . . . . . .. . . . . .
Name
. . . . .. . . . . . . . . . . . . . . .. . . . . .
Designation
D. . . . .. . . . . . . . . . . . . . . .. . . . . .
Office
# 3 . . . . .. . . . . . . . . . .
 [ . . . . .. . . . . . . . . . . . .. . . . .
Date of appointment
T.No.
Rate of pay
= 3 . . . . . .. . . . . . . . . . . . . . . .
Date of retirement

1 .  YZ
\ U .

We certify that to our knowledge, the parties for whom Privilege Pass/PTO are required are as
described on the reverse.

:6. . . . . .. . . . . . . . . . . . . . . .
Signature

:6. . . . . .. . . . . . . . . . . . . . . .
Signature

Daughters or Step-daughters or adopted daughters, unmarried/widowed/married under

18 years

. . . . . .. . . . . . . . . . . . . . . .
Designation

. . . . . .. . . . . . . . . . . . . . . .
Designation

school/college or invalid

. . . . . .. . . . . . . . . . . . . . . .
Department

. . . . . .. . . . . . . . . . . . . . . .
Department

' ' = ' 21 D /21 D : /

I Sons or step sons or adopted son under 21 years/over 21 years attending
21 D /21 D / I

Brothers or step brothers under 21 years/over 21 years /over 21 years attending

school/college or invalid
D 6 Nurse or governess or guardian
  N Attendant employed on the regular basis in
the person service

'

Outward journey

From

'

Inward journey

. . . . . . . . . . . . . . . . . . . . . . ..

. . . . . . .

. . . . . . . . . .. . . . .

To
. . . . . . . . . . . . . . . . . . . . . . ..

From

....... ........ . ......

To

. O . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. .D
Class to which entitled

' .. . . . . . . . . . . . . . . . . .
Break journey at

Railway

........................ .. .

( Q

/For free pass only )

Route

.. . . . . . . . . .
Date from which required

. . . . . .. . . . . . . . . . . . . . . .. . . . . . . . . .
Foreign line

. . . . . .. . . . . . . . . . . . . . . .. . . . . . . . . .
Home line

1 . . D  . . . . .. . . . . . . . . . . . / 
Certified that the applicant during the year has had

Pass/P.T.Os.

. . . . . .. . . . . . . . . . . . . . . . . . . . .
/Pass Clerk

1 /Issuing Officer

: /Sanctioned

/  . . . . . . . .
Pass/P.T.Os No.

. . . . .. . . . . . . . . . . . . . . .

. D  D

issued and noted on Index Card.



(
 )
Signature of thumb impression of the recipient
(If at the same station where it is issued)

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