Railway Recruitment Cell

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

Read the guidelines carefully before you start filling up the application Form Employment Notice No.0110/2010

For Office use

1. Name of the candidate

2. Fathers/ Husbands Name 3. Nearest Railway Station 4. Address for Correspondence

5. Sex 6. Nationality 7. Religion 8. Marital status

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

State
9. Date of Birth : Date Month

PIN
year

Contact Phone Number with STD code

10. Persons with Disabilities 13. Order of preference (Post code upto 5 preference)
1st
2nd 3rd 4th 5th

11. Community

12. Age Relaxation

14. Educational qualification tick( ) the appropriate column

SSLC/ Matric HSC / SSC ITI Diploma Non Technical
Graduate Post Graduate

15 Serving Employee
Technical

16. If Yes, indicate the organisation

Graduate Post Graduate

17. Fee Exemption 18. Choice of Language for Examination

19. Personal marks of identification

1: Date : 3. Specimen signature Amount: Left Thumb Impression

2: 20. Details of IPO/DD No. Name of the Post Office / Bank & Place 1. Specimen signature 2. Specimen signature

DECLARATION BY THE CANDIDATE 21. 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 :

Signature of the candidate