Annexure-1

Control No (for office use):Roll No (for office use):-

RAILWAY RECRUITMENT BOARD,

PLEASE FILL UP THE APPLICATION IN

........................................ Paste(do not pin or staple) Paste(do not pin or staple) here your recent colour here your recent colour passport size photograph of passport size photograph of size size 4 cm x 5 cm 4 cm 5 cm (The colourxphotograph (The not be more than shouldcolour photograph3 shmonths old)moreto be 3 ould not be Not than months old) Not to be attested. attested.

APPLICATION FORM FOR Centralised Employment Notice No 02/2010

NO. ......

CAPITAL LETTERS IN OWN HANDWRITING. Signature should not be in Capital letters.

Cat No Name of Post

(All applications must be submitted in A4 size 80 GSM bond paper)

1. Category No & Post

(For single category) Indicate options below in order of preference where single application is prescribed for more than one category (you will only be considered for the posts indicated below ) Option Cat No Name of Post

1 2

2.

Choice of Railway:
(wherever applicable)

1st

2nd
of concerned RRB

3rd

3.

Medium of examination : (Choose any one of the local languages

as given in para 15 of notification , if other than English, Hindi & Urdu)

Signature of the candidate in the above box below the photograph

4. 5.

NAME OF CANDIDATE
(In English only)

COMMUNITY (Tick )

UR

OBC*

SC*

ST*

* Community Certificate to be submitted in the form as prescribed in Annex -03 or Annex -04 as applicable

6. FATHERS NAME
(In English only)

7. Date of Birth (DD/MM/YYYY)

8. Age

years

months

days

(Age as on 01.07.2010, refer para 2 of Emp. Notice No. 02./2010)

9. Visible mark of identification on body

10. Qualification (Fill in only those qualifications prescribed for the post applied for) Year of (A) Academic Qualification University/Board passing SSC/X / Matric Higher Secondary/XII/Inter Graduation Post Graduation Others (B) Technical I.T.I. /Act Apprentice Diploma Engineering Degree Others 11. ADDRESS
(In English only)

Subjects

Marks %

Qualification

University/Board

Year of passing

Discipline/Trade

Marks %

(FOR CORRESPONDENCE)

State__________________________ PIN CODE

12.

Nearest Railway Station

(In English only ) (for issue of free railway pass to SC/ST candidates)

Left Hand Thumb Impression of candidate in this box

Signature of the Candidate

Note : 1) Candidate must fill up their name, father's name and date of birth as indicated in their Matriculation certificate. 2) Candidate should put their full signature at all the places in the same language (In English or in Hindi)

Annexu re-2 Ra ilway R ecruitment Board , . . . . . . . . . . . . . . . . . . . . . . . I n f o r m a t i o n S h e e t ( F o r C e n t r a l i s e d E m p l o y m e n t N o t i c e N o . 0 2 / 2 0 1 0 )

(To be filled in CAPITAL LETTERS only Signature should not be in Capital /Open letters)

1. Name of Candidate (In English only)

2.

Tick( ) Gender

3 . Na tio nality

Female

Male

Marital Status

Married

Unmarried

4. P e rmanent Add ress : _____________________________________________________________

________________________________________________________________________ ___________________________________________ State____________Pin cod e __________

5.(a) Details of Postal Orders/Demand Drafts enclosed:Name of Post office/Bank Serial No. & Date Amount

5.(b) Are you seeking Fee exemption (Y/N)

( ) Tick appropriate box from the following (i) As an economically backward class candidate (iii) As a Female candidate (Income certificate to be enclosed as per annexure-7) (iv) As a SC/ST candidate (ii) As a minority candidate(self declaration to be enclosed as per annex-8) (v) As an Ex- servicemen Muslim Christian Sikh Buddhist Parsi (vi) As a Physically Handicapped

6. Religion : Hindu Muslim Christian Sikh Buddhist Jain Parsi other 7. Are You (i) Govt. Employee (Y/N) (ii) Ex-serviceman(Y/N) (iii) Physically Handicapped (Y/N) if yes then deformity (VH/OH/HH) 8 . Present employment (To be filled by all Railway/Central/State/PSU employees) Designation & Grade 9. Ex-serviceman(Ex-SM) Date of Enrolment Date from Date to Name & address of Employer

Date of Attestation

Date of Discharge

Length of Service

10 Do you seek age relaxation TICK ( ) appropriate box

SC ST OBC Judicially separated / divorced woman /widow J&K Resident Ex-SM Railway Employee Course completed Act Apprentice Physically Handicapped

Documents attached in proof of : Indicate by ( ) Tick mark in the relevant boxes indicated below:Community Certificate(For SC/ST/OBC) Self Declaration Certificate (For OBC candidates as per Annx-5) IPO/DD Discharge Certificate (for Ex-serviceman) Colour Photograph (Passport size) Date of birth Certificate (As per Matric/High school or equivalent) Educational Certificate Vision Certificate( required for the post of ASM/ALP as per Annex -6) Disability Certificate(For Persons with Disability as per Annex-9) Declaration from VH/ affected by cerebral palsy (For Engaging scribe as per Annexure-10) Economically backward classes certificate(For Economically backward classes as per Annex-7) Minority self declaration certificate(For Minority community as per Annex-08)

11. 12.

Whether you were debarred by any RRB in the past

a) No

b) For 2 years

c) For life

13. Please copy the following declaration in your own hand writing in running hand in the space provided below: I hereby declare that all the statements made by me in the application are true and complete to the best of my knowledge and belief and nothing has been concealed or suppressed. I also understand that in case, any of my statements is found untrue during any stage of recruitment or thereafter shall disqualify me for the post applied for and/or I shall be liable for any other action under the extant rules._____________________________________________________________________________________________

__________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________

Left hand Thumb Impression of candidate in this box

Place : Date:

Signature of the Candidate