. Train No. & Name. RAILWAY RESERVATION/CANCELLATION REQUISITION FORM, you ace 2 Medical Practitioner, please tck (7) in box Dr (You could ba of elp in an emergency) Ifyou ate Pregnant Women and want to get Berth in Quoi please tek (¥) th box yes, plesse submit cetficale of Regs. Doctor. ‘you want Sr. Citizen Coneession, please write VIESINO in box . . Giyes, please cary a proof of age during the joumtey to avekd inconvenience of peat a ‘Samrging under extast Railway Rules) 1 you want to give up Si. Cislaen Convession, please indlcage tbe Plement oF concessional ‘anount, you Want tg give up 5% [or tom) ‘Do you wait to be paraded without any extra charge? Writs YES/NO in the box. (OF this option isnot exercised, ull fae paying passengers may be upgraded autorsaleally) you want to get shifted. slirnate train under “VIKALD” scheme, please wrte YES/NO in the box. {aly for waiting lst tickets), Chose “WIKALP far trains leaving within: 12 hours 3, 24 hours J , 48 hours] you are traveling in 3 AC Class of Garib Rath Expres’ Trainor in Sleeper Clase oF Daronto Express Train, do you want becoll In tain? Write YES/NO in the box. i 1 Dass of Youre. o,f Berths Seas... Class... Smtion From. 3 as Boarding a. NII Reseration up. : MobIleN. onsen (for PNR Set pitt SMS) S7]_Nemot Biosk cars Gander [ABE Choice afer | Mea Oplion” for Reicha] Mo. | -(eormor shen 13 Tore) Nationa MU oF itary (LB/UB) | SheebdiDurcate taias Autocity | In cateberth ot | Do you want to eke meal | No. lequied for ebildea | Tick) yes ot age’ ys aud | yoq , coins [YL MO _ Nos [eg Now-Ve z = — ; 7 = ps he ti pas - — |— z : : Sis ‘Name in Block Laties MOD ae T — 7 - ‘Train No, & Name. Chass, Nome of Applicat... Full Address. ‘Radha No.(Optional). Signature of the ApplicantiRepresentative TOR OMMIGALISEONLY 8.No. of Requisition, cst PNR, Berta’ No aie Amount olsced.. Signature of Reservation Cert We