SOUTH CENTRAL RAILWAY Divisional Office,

Personnel Branch,
Guntakal Dt. . .2021.
No.SCR/P-GTL/100/RRC/18
To

Com: Roll No:

Sub:- Offer of appointment to the post of Track maintainer-IV/APM/Helper in.

Dept. in Pay band Rs. 5200-20200 with G.P. Rs.1800/- (Level-1) - selected by
RRC/SC and allotted to Guntakal Division, SC Railway.

Ref Chairman RRC/SC Letter No.RRC/SCR/SC/Group-D/CEN/02/2018. Dt. .07.2019.

*

You have been selected for the post of by RRC/Secunderabad in

_Department, in pay band Rs.5200-20200 with G.P Rs.1800/-(Level-1) plus D.A and
other allowances as admissible under the rules in force, from time to time, subject to the
following conditions.

1. You must produce necessary documents in original for verification of your Caste, Date
of Birth, Educational /Technical and other qualification certificates, TC etc. when you
report to this office, besides PAN CARD Xerox copy.
You will take Oath of allegiance to the Union of INDIA.
3 You should also produce 06 recently taken passport size
photographs
. Your service after appointment as in the regular cadre will be
provisional, the first two years of which you will be deemed to be on probation. You will
not be entitled to any notice of termination due to expiry of the officiating vacancy or is
due to mental or physical incapacity or to your removal or dismissal as a disciplinary
measure after compliance with the provisions of clause (2) of the Article 311 of the
Constitution of India, otherwise your services will be terminable on 14 (Fourteen) days
notice on either side.
Your continuance in service therefore is subject to:
a) Your qualification in the duties prescribed for the post you hold.
b) Your fulfilling such other general conditions of service as may be laid down from time
to time.
c) Your furnishing a declaration regarding plural marriage as required in Railway
Board's letter No. E.54/RP 1/26 dt. 26.1.1954.
d) You must be prepared to serve anywhere, any station in GTL Division/S.C.Railway.
You will not be eligible for any pension or any benefit under the State
Railway
provident Fund or Gratuity or to any absentee Allowance beyond those admissible to
temporary employee under the rules in force, from time to time.

Contd P.2
 claim of seniority over those
1. Your out of turn appointment will not confer on you any
determined according to the
who are higher up in order of merit. Your seniority will be
to you in due course.
rules in force, and the correct seniority position will be notified
for the charge and care of Govt. Money,
Goods and stores
8. You will be held responsible
and all other property that may be entrusted.
be liable for Military
9. Every individual appointed to the above post shall, if required,
and 3 years in the
services in the Railway Engineering of the Territorial Army service
Territorial Army/Reserve or for such period as may be laid
down in his behalf from

time to time.
the conditions stipulated above, please call
10. If you intend taking up the appointment on

at this office on .
at 02:30 hrs, with the original certificates including your
which this offer will not be
SSC/ SSLC, ITI, Sports, TC, Disability certificate etc., failing to
and money)
renewed, you should come prepared (with sufficient clothing, bedding
No further time or
take up appointment to join the station at which you are posted.
permission to take up the appointment at a later date will be granted.
to which you are
11. Your pay will commence from the date you join duty at the station
posted.
In case, if you belong to SC/ST/0BC community you should produce latest Community
12.
Revenue
certificate from a Revenue Official not lower than a rank of Tahsildar/Mandal
Officer.
enclosed from the Head
13. You should also produce character certificate in the proforma
attested by 1st Class
Master/Principal of Educational Institution you last studied duly Sub-Divisional
Executive Magistrate/District Magistrate (District Collector)/
Magistrate (RD0). should
14 You should bring the enclosed attestation forms duly filled in all respects. You
also come prepared, to take up appointment if found fit in all respects.
01.01.2004 in terms of
15 You will be governed by New Pension Scheme introduced w.e.f
Railway Board's letter No.F(B)IL/2003/PN/24 of 31.12.2003.
Your appointment is also subject to verification report from
Civil Authorities that there
16.
received from District
is nothing adverse against you. In case any adverse report
Collector this Offer of appointment will stand cancelled without any intimation to you.

Encl: 1. Attestation Form

2. Character certificate
3. Caste Certificate Pro forma

Assistant Personnel Officer

Date:. 2021
Place: GUNTAKAL.
S.C. Railway, Guntakal.

accept the office offer of

Son o f
No.SCR/P-GTL/100/RRC/18. issued by the Assistant Personnel Officer,
appointment
S.C.Railway, GUNTAKAL.

Signature of the candidate

 DIVISIONAL RAILWAY MANAGER/ PERSONNEL/GUNTAKALL
JuldrpeUI D#Å ATTESTATION FORM
N. E.No. T Post
fe .
Category No._ ia Roll No. _

WARNING The fumishing of false information or suppression of any factual information in the Attestation fom
would be a disqualiíication, and is likely to render the candidate unfit for employment under the Government.

Affix signed passport If detained, convicted debarred, etc., subsequent to the completion and
size (5cm x7cm subrnission of this form, the details should be communicated immediately
approx.) copy of recent to the Union Public Service Commission or the
photograph where
Railway Recruitment
Board or the authority to who the Attestation.Form has been sent earlier,
asked for
as, the case may be, failing which it will to deemed to be a
"supression of
factual infomation."

If the fact that false information has been furnished or that there has
been suppression of any factual information in the attestation form comes
to notice at any time during the
service'of person, his,services would be
liable to be terminated.
.

Name in full n block

Sumame T Name
capitals) with åliases, f any.

(Please indicate" if you have added or dropped in

any stage any part of your name or sumame).

Present address in full (i.e. Village, Thana and

District of House Number, Lane/Street/Road and
Town)

(a) House address In full (.e., Village, Thana and

Disrictor House Number, Lane/Street/Róad and|
Town and name of Dlstrict Head quarters).
...

(b) If origlnally a resident of Pakistan, the

in that country and the dale
address
ofmigration Indian|
to
Union.
 Page 2

Particulars of places (with periods of residences) where you have resided for more than one year at a time
during the
preceding five years. In case of stay abroad (including Pakistan) particulars of all where you
have resided for more than one year after attaining the
places
age of 21 years, should be given.

From To Residential address in full (i.e., Name of the District

Village, Thana and District or Headquarters of the Place
House Number, Lane/Street mentioned in the preceding
Road and Town) column

Place
Name in full
of
with aliases
birth
if any

5. (i) f i
Father..
Cii) am
Mother
(ii) rt/Ti
Wife
Husband.
(iv) (H)(1)
Brother (s)
(i)
(iv)
(V)
(v) a(tN2)| .

Sister
(ii)
(iv)
 Page: 3

(2)
(a) Information to be furnished with regard to son(s) and/or daughter(s) in case they are studying/
living in a Foreign Country.

Name Nationality (by Place

birth and/or by Country in which Date from which studying/living
of
studying/living with in the country mentioned in
domicile) birth full address previous column

6.
Nationality
7. () ad ()
(a) Date of Birth (a)

(b) PresentAge ()

(c) Age of Matriculation

8.

(a) Place of Birth, District and State in (a)

which situated

(b) District and State in which you belong. (a)

(b
(

(o) District and State in which your Father

originally belonged ?

9. 5
(a) Your Religion (a)
()
(b) Are you a member of a Scheduled Caste /
Scheduled Tribe ? Answer "Yes" or "No" ()
and if the answer is "Yes" State the name
thereof.
 Page:4

Educational qualifications showing places of education with years in Schools and Colleges since 15th
year of age.
Name of School/College Date of Date of Examinalion
with full adress Joining Leaving Passed

(a) Are you holding or have any time held an appointment under the' Central State Government or a
Semi-Government or a Quasi-Government body, or an autonomous body, or a Public Undertaking
or a Private Fim or Institution ? If so, give full
particulars with dates of employment up-to-date.
-

Period
Full name and address
Designation, Enoluments of the èmployer Reasons for leaving
and nature of employment previous service
From To

(b) If the previous employment was underthe Government of tndla, a State

Government an undertaking owned or controlled by the Government of
india or a State Government / an autonomous body / University 1 Local
body:
.. ff you had left service on giving a month's notice under 5 of the Central
Civil Sevice (Temporary Service)Rules,19B5, a notioa tor the preecribed
period under Rule 149 ofthe indian Ralway Establlshment Code, Vol-4, or
any simllar corresponding rules, were any disclplinary proceedingsframed
agalnst you or had you been-called upon to explaln your conduct in any
matter at the time you gave notlce of terminetlon or servlce, or at a
Subsequent date, before your services actually terminiated ?
 Page: 5

M2. (5) TNI 3N9 fri ¥m Aryar fHN T B,?

a) Have you ever been arrested ? Yes/ No
(a) q fo V 3T7 3n9ruifora gy ?
(6) Have you ever been prosecuted? Yes / No

(c Have you ever been kept under detention ? Yes / No

d) Have you ever been bound down? Yes/ No

(e) Have you ever been fined a Court of Law? Yes/ No

() Have you everbeen convicted by a Court of Law for any offence? Yes/ No

Aa ?
(9) Have you ever been debarred from any examination or rusticated by any Yes/ No
University or any other education authority/lnstitution ?

(h) Have you ever been debarred/disqualified by any Railway or Public Service Yes / No
Commission for any of its examination/selections ?

TVEI?
I s any case pending against you in any Court of law at the time of filling up this Yes/ No
Attestation Form ?

()ls any case pending against you in any University or any other educational Yes/ No
authoritylinstitution at the time offilling up this Attestation Form?

(K) Whelher discharged/expelled/withdrawn from any Training Institution under Yes /No
the Govt. or otherwise?

(b) If the answer to any ofthe above mentioned questions is "Yes", give full
particulars of the caselarrest/detention/finelconviction/sentence/punishrment,
etc., and/or the nature of the case pending in the Court/University/Educational
Authority, etc., at the time of filing up this form.

Note: (i) Please also see.the "Waming" at the top of this Attestation Form.
(i) Specific answertoeachofthe questlon should be given by striking out "Yes" or "No" as the case may be

(1)
13. Names of two responsible persons of your locality and address or| (2)
two references to whom you are known.

Certiy that the foregoing information is.correot:and complete to the best of my knowledge and pele
I am not aware of any circumstances which might impalre my fitness for employment under Government.

Signature of Candidate:
Fe Place
fis Date
 Page 6

UEH HY-TA IDENETITY CERTIFICATE

Certificate to be signed by any of the following

(i)
Gazetted Officer of Central or State Government.

(i)
Members of Parliament or State Legislature belonging to the constituency where the candidate or his
parent is ordinarily resident.

(ii)
ub-Divisional Magistrates / Officers.

(iv)
Tahsildars or Deputy Tahsildars authorised. to exercise magisterial powers.
(v)
Principal Head Master of the recognised School/ College where the candidate studied last.

(vi)
Block Development Officers.

Pahchayat Inspectors.

Certified that I have known Shri./Smt./Kum. Soni

Daughter of Shri. for the last
years months
and that to the best of my
knowledge and bellef particulars furnished by him/her are correct.

FRar Signature.
Te Place

fei Date

Designatlon status
and address

********
 Page
(FÍay i 4ð } fey To be filled by the Office)

Name
()
designation and all address of the Appointment
authority
Post for which the candidate is being considered.

* .i :
 Pass Port siz
photograph of
the candidate
should be affixed
duly attested by
Gazetted Oficcr

CERTIFICATE OF CHARACTER/DENTITY
(For Group 'C' Class-III service)
-

Certified that I have known

Sri/Smt./Kum. Son/
Wife/Daughter of Sri/Smt./Kum.
for the last
years months and that to the best of my knowledge and
belief, he/she bears reputable character and has no antecedents whiçh render him/her
unsuitable for Government
Employment.

Sri/Smt./Kum. is not related to me.

Place
Signature
Date:
Designation:
(To be signed by the Head of the Educational Institute last
employee, if any) attènded and certificate from

ATTESTED
Place:
Signature:
Date
Office Seal: Designation:
(Attesting Authority)

(To be attested by stipendiary Jst cla_s ëxcutive

Divisional Magistrate). Magistrate/District Magistrate of Sub-
 FORM OF CASTE CERTIFICATE FOR SC/ST
This is
certify that
to Shri/Smt/Kum* **

Son/Daughter* of Shri of Village / Town

District/Division* of the
State/Union Territory belongs to the. Caste /Tribe which is recognized as a Scheduled
Caste/Tribe under:
The Constitution Scheduled Castes Order, 1950.
The Constitution Scheduled Tribes Order, 1950.
The Constitution (Scheduled Castes)
(Union Territories) (Part C States) Order, 1951;
The Constitution (Scheduled Tribes) (Union Territories)
(Part C States) Order, 1951;
[As amended by the Scheduled Castes and Scheduled Tribes List (Modification Order, 1956, the Bombay
Reorganization Act, 1960, the Punjab Reorganization Act, 1966, the State of Himachal Pradesh Act, 1970, the North Eastern
Areas (Reorganization) Act, 1971 and the Scheduled Castes and Scheduled
Tribes Orders(Amendment) Act, 1976]
*The Constitution (Jammu and
Kashmir)* Scheduled Castes Orders, 1956.
*The Constitution (Andaman and Nicobar
Islands)* Scheduled Tribes Order, 1959, as amended by
the Scheduled Castes and Scheduled Tribes Orders
(Amendment) Act, 1976.
The Constitution (Dadra and Nagar Haveli)* Scheduled Castes
The Constitution (Dadra and Nagar Haveli)* Scheduled Tribes
Order, 1962.
Order, 1962.
*The Constitutiou (Pondicherry) Scheduled Castes
Order, 1964.
*The Constitution (Uttar Pradesh) Scheduled Tribes
Order, 1967.
The Constitution (Goa, Daman and Diu) Scheduled Castes
*The Constitution (Goa, Daman and Diu) Scheduled Tribes
Order, 1968.
Order, 1968.
The Constitution (Nagaland) Scheduled Tribes Order, 1970.
*The Constitution (Sikkim) Scheduled Castes Order, 1978.
*The Constitution (Sikkim) Scheduled Tribes Order, 1978.
The Constitution (Jammu & Kashmir) Scheduled Tribes
Order, 1989.
*The Constitution (SC) Orders (Amendment) Act, 1990.
*The Constitution (ST) Orders
(Amendment) Ordinance Act, 1991.
*The Constitution (ST) Orders
(Amendment) Ordinance Act, 1996.
The Constitution (Scheduled Castes) Orders
(Amendment) Act, 2002.
*The Constitution (Scheduled Castes) Orders (Second
Amendment) Act, 20002.
The Scheduled Castes and Scheduled Tribes Orders
(Amncndment) Act, 2002.
2. Applicable in the case of Scheduled Castes/Scheduled Tribes persons who have migrated from one State/Union
Territory Administration.
This certificate is issued on the basis of the Scheduled Castes/Scheduled Tribes Certificate issued to
Shri/Shrimati*. father/mother* of Shri/
Shrimati/Kumari . of Village/Town* in
District/Division* of the State/Union Territory* who belongs to the
Caste*/Tribe which is recognized as a Scheduled Caste/Scheduled Tribe in the Stution/Union Territory*
issued by he dated

3. Shri/Shrimati/Kumari* and l or* his her* family ordinarily reside(s) in Village/Town*

District/Division* of the State/Union Territory* of

Place
Date:
Signature.
Designation
(With seal of office)

*Please delcte the words, which are not applicable. State/Union Territory
Please quote specific Presidential Order.
%Delete the Paragaph, which is not applicable.
Note
(a) The tenn ordinarily reside(s) used here will have the same meaning as in Section 20 of the Representation of the People Act, 1950.
The following Officers are authorized to issue caste certificates:
1. District Magistrate/Additional District Magistrate/Collector/Deputy Commissioner/Additional
Stipendiary Magistrate/Sub Divisional Magistrate/Taluka Magistrate/Executive Magistrate/ExtraDeputy Commissioner/Deputy Collector/lst Class
Assistant Comnissioner.
2. Chief Presidency Magistrate/Additional Chief Presidency Magistrate/Presidency Magistrate.
3. Revenue Officer not below the rank
of Tahsildar.
 OBC CERTIFICATE EORMAT
EORMAT OF CERTIEICATETO BEPRODUCED BYOTHERBACIKWARD CLASSES APPIYING
FORAPPQINTMENTTO POSTUNDER THEGOVERNMENT OF1NDIA.
This is to certify that Shri/Smt/Kum*-
Son/Daughter* of Shri of Village /Tow
District in State
ás backward class
belongs to community which is recognized,
under : (indicate the Sub Caste)

1. Resolution No. 12011/68/93-BCC@dtu 10th September 1993, published in the Gazette of lndia- Extraordinary Part-
I, Section 1. No. 186 dated 13th September 1993.
2. Resolution No. 12011/9/94-BCC dated 19th Ocober 1994, published in the Gazete of Indla-Ektraordinary Part:l,
Section I. No. 163, dated 20th October1994.
3. Resolution No.12011/7/95-BCC dtd 24th May 1995, Published in the Gazette ofIndia-Extraordinary Part-l, Section
L. No. 88 dated 25th May 1995.
4. Resoluion No. 12011/44/96-BCC dtd 6th December 1996, publishedinthe Gazette of India-Extraordinary Part-l,
dated
Section I. No. 210, 11th December 1996.
5. Resolution No. 12011/68/93-BC, Published in Gazette of Indi - Extra Ordinary- No: 129, dated the 8thFjuly 1997.
6. Resolution No. 12011/12/96-BCC, Published in Gazette of India - Extra Ordinary No. 164 dated the 1stSept.1997.
7. Resolution No. 12011/99/94-BCC,Published in Gazette of India - Extra Ordinary- No. 236 dated the 11th Dec: 1997.
8. Resolution No. 12011/13/97-BCC, Published in Gazette of lndia - Bxtra Ordinary- No.239dai|d the 3rd Dec. 1997.
9. Resolution No. 12011/12/96-BCC, Published in Gazette of lndia - Extra Opdinary- No. 166.dated the 3rd August 1998
10. Resolution No: 12011/68/93-BCC, Published in Gazette of India - Dxtra Ordinary - No. 171 dated the 6thAugust 198.
11. Resolution No. 12011/6898-BCC,Published in Gazette of India - Extra Ordinary-No.241 datod the 27ti.Oct. 1989
12. Resolution No. 12011/88/98-Bcc, Published in Gazette of ndía - Extra Ordinarý- No.270dated the 6th Dec.191.
13. Resolution No: 12011/36/99-BCC, Published in Gazette of India - Extra Ordinary - No. 71 dated the 4th April 2000.

Shri/Smt/Kum*. and or his/her family

ordinarily re_ide(s) in the District of the- Statt.
This is also to certify that he/she does not belongto the persons/ sections (Creamy Layer)
mentioned in Column 3 (of the Schedule to the Government of India, Departmen: of
Personnel and Training 0.M. No. 36012/22/93/Estt. (SCT) dated 08.09.1993) and modiñed
vide Government of India, Department of Personnel and Training O.M. Nu.

36033/3/2004/Est.(RES).Dated 09:03.2004..
District Magistrate/
Place: Dy. Commissiorier Etc
Date (withseal of of ce)
a. The term ordinarily used here will have the same meaning as Section 20 of the representation ofthe Peop:e
Act. 1950.
b. Where the certificates are issued by Gazetted Officers of the Union Government or State Governments, they
should be in the same form but countersigned by the District Magistrate or Dy. Commissioner (Certificates
issued by Gazetted officers and attested by District Magistrate/Deputy Commissioner are not sufficient).
c. The 0BC certificate from the authorities onlywill be accepted.
1. District Magistrate/Additional District Magistrate/Collector/Deputy
Commissioner/Additional Deputy Commissioner/Deputy Collector/1" Class Stipendiary
Magistrate/Extra-Assistant Commissioner (not below the rank ofl" Class stipendiory
Magistrate)/ *Sub divisional Magistrate/Taluka
Magistrate/Executive.Magistrate.
2. Chief Presidency Magistrate/Additional Chief Presidency Magistrate/Presidency Magistrate.
3. Revenue Ollicer not below the rank of Tahsildar, and'
4. Sub-Divisional officer of the area where the candidate and/or his family noimally resicles.

14
 CSRF
Ver 1.5
NATIONAL PENSION SYSTEM (NPS)-SUBSCRIBER REGISTRATION FORM
Central Recordkeeping Agency (CRA) -
NSDL o-Governance Infrastructure Limited

Afflx
Contral Govt State Govt recont pholograph o
Ploase soloct your catogory Contral Autonomous Body Stato Autonomous Body 3.5 cm x 2,5 cm szo l

I Ploaso tlck(")] All Ciuzon Modol Corporate Soctor Passport size

NPS LIte (GOS)

Nalional Pansion System Trust.

Dear SirMadam,
hereby request that an NPS account be opaned in my name as per the particulars given below
indicatos mandatory fiokds. Ploaso fill the fom in English and BLOCK letters with black Ink pen. (Rofur genorad guidoánes at instuctions pago)

KYC Numbor, Rouremont Advisor Codo and Spouso Namo fields aro not appllcablo for Goveminent &NPS Lite Subscrbers
KYC Number (if applicable) Generated from Central KYC Registry
Retirement Adviser Code (fapplicable)
PERSONAL DETAILS: 1eerioSNo1aheSmt.
ngiklons Kumari U
Name of Applicant in full Shri
First Name
Middle Name
Last Name
Subscriber's Maiden Name (fany)
Father's Name
(Refer St. No, 1 of instrucions)

Mother's Name"
(Refer Sr. No.1 of instructions)
Falher's name wil be printed onPRANcard.In case,mothar's nameto beprintedinstead of tather's name [ Plaase tick ()1
(Date of Birth should be supported by reovant documentar proot)
Date of Birth
City of Birth
d mmylyyly
Country ofBirth
Gender [Please tick( 1 Male Female Others Nationality Indian
Marital Status Unmarried Others
Married
Spouse Name L s| LLMdjd|e L
(Relar St. No. 1 of instructions)

Residental Stalus Indian

2 PROOROFIDENTIPoU (Any oneofihedocumentsneedtobe providod alongwhtheidentificationnumber)

Passport Passport Explry Date
Voter 1D Card PAN Card
Driving License Driving License Expiry Date na|/YyLz
NREGA JOB Card
Others Name oflhe1D | DNuT PsoraferSt.No,2oftheinstucions
UID (Aadhaar) UiDI [Aadhaar] number not requlred.)
As pertheamondments madeunderProvontionofMoneyLaundering(MainlananceofRocods) Socond AmendmentRule5,
d Prese0, pease Onsuretnal those delaus are prOvided within six months submiss/on
of Reglstrallon
of this
2079,PANorFam60is mandatoay underNPS."youdonothave PAN
Subsclber Fom.

3RROOF OF ADDRESS (ROA icoQSPondonco Address a ID cardNAEGA s Job PomanentAddres. t atoi

[Please tick (), as applicable Passport Orting LicensauD (AadhaarVoder Passpor Dring censeUID [AadhaarVoer 1D caráNAEGA Jod
#Not more than 2months old. CardRation CardOthars CarcHangn CardtinerS
ogsterod Loasa/Sale apreement of rasidonco Municipal Tax Hoglstered Lease/Salo agroament of rosidencoMunicipal Tax
Please refer Sr. No. 2 of the instrucions
Recolpt
Lalest Piped Gas/Walo/Eloctricity/Telaphone|Landline or postpald Latest Piped GasWalet Electicity/TelaphonelLandlina or pastpaid
mobilel Bi moblle E

43 CORRESEoNDENGEADDBESSDEIAES
Address Type ResidentialBusiness Residential Business Registered Office Unspecified
FlaURoom/Door/Block no. Landmark
Premises/Building/illage
Road/StreetLane
AreaLocality/Taluk
City/Town/District PIN Code
State/U.T. Cou n ryl
KPERMANENTADDRESS DEALS: nikncazotheasdesl saea3bove
Address Type ResidentiavBusiness Residential Business Registered Office Unspecified
FlaURoom/Door/Block no. Landmark
Premises/Building/Village
Road/Street/Lane

AreaLocality/Taluk
City/Town/District PINCode
State/U.T.
1 of 5
Ver1.5 CSRE
5. CONTACT DETAILS
Tel. (O) (with STD codo) Tl. (Res):(with STD code)
9 1 (Mobile Number is roquired for communication and to get SMS alerts)
Mobile" (Mandalory)
Email ID

6 OTHERDETAILS(Pegse.relerto.Sreclthenetiuclons) 2d 13s E
Occupation Details I ploasetick()1
Private Sector Public Sector Government Sactor Profassional
Self Employed Homemaker Student Olhers (Please Specly)
Income Range (per annum) Upto 1 lac U 1 lac to 6 lac 5 lac to 10 lac 1 0lac to 25lac 25 lac and above
Educatlonal Qualifications Below SSC L SSC HSC Graduate Masters Professionals (CA, CS, CMA, etc.)
Please Tick If Applicable Politically exposed person L Related to Poltically exposed Person (Plaasereferinstruction no.3)

7sSUBSCRIBER BANKDETAJLS (Pwerla.o.SKhedsithe.heeci

(All the bank details are imandatory except MICR Code.)
Account Type t please tick() 1_ Savings A/c Curent Alc
Bank Alc Number

Bank Name
Branch Name
Branch Addrass PIN Code
Statelu.t. L
Bank MICR Code IFS Code

SUESCRISERS NOMINATIORDEIALSPaSa1dorkSENsoensncon KDN i

Name of the Nominee (You can nominato up to a maximum of 3 nominoes and if you desira so ploase fil in Annexure ll (Additional Nomination Form) providedaeparately)
- Middle Name
FirstName Last Name

Relationship with the Nominee Date of Birth (dln case of Minor)ddZ A *************
yy
Nominee's Guardian Details (in case of a minor)
Middle Name Last Name
First Name

9NPS OPTION DETAILS (Please uck..es.applicabl) a LZN

YES N O I f Yos, ploase submit detalsla Annoxura l.
I would like to subscribe for Tler I Account also
ar you ish to activate Tier l account subsoquend, you may submt separate aplicaton (Anneaure $10) to the associatod Noda orfca or to POPPOP-SPof your cholce. The ist ofPOP
POP-SPs rendering services under NPS and Anneure S10 Is available on CRAwebsile)
I would like my PRAN to bo printod in HIndl YES NOIfYos,ploaso submit dotails onAnnexurei_
10. PENSIONFUND(PESELECTIONANDINYESTMENT.ORIONILEeaseieferioSr.ne.9atthelostud.ens)
() PENSION FUND SELECnON (Tior ): Phaso road bolow conditlons boforo opting for tho cholcoof Pansion Funds:
1. Govammant Sector: The follawing Pansion Funds (PFs) wil act jointy as default PFs.fchoicoisnot exarcised by the government amployelsubscrber
(a) uC PensionFund Umited() SBI Pension FundsPt. Umited (o) uTI Roroment Solutions Lidlin caso of Central Autonomous Bodies CABYStateGovernment
(SG/State Aufonomous Bodios (SAB) employes, aelection made under this secion will be ignored, it cholce to employeas is not notifed by the rospeclve Stale

GovUMinistry.
2. All Citzen Model Subecribars under All Ctizon model have the opton to chooso theavalale PFs as per heir cholce in thetablobolow
3. Corporate Model: Subscribers shal have the option to choose the available PFs as per the below table in conaultlation with their respecdive Employor
NPS Lie: NPS Lie is a group cholce modol where subscriber has a choiceofPF andinvestmantoplionas availatiewith Aggregator.
Ploaso Tlck () Default Cholce of Penslon Funds
Name of the Ponsion Fund(Poasesoloctonlyono)
|LIC Penslon Fund Limited
Available in Govemment secdor, if omployea/subscriber does nol exerise
SBI Pension Funds Private Lmited choice ofPF
Oeurement Solutons Limited

ICICI Prudential Pension Funds Management Company Limited

Kotak Mahindra Pension Fund Limited

HOFC Pension Management Company Limited

Birla Sunlfe Pension Managemant LImited
Selection of 01 Penslon Fund Is mandatory for All Citzen subscriber

(U) INVESTMENT OPTION

(Please Tick () in the box given below showing your Investment option).

Acdive Choice Auto Cholce

Please note:
1. In caso you selectAdtive Cholce fill up secion (i) below and if you selec Auto Choico fill up section (iv) below.
2. In case you do not Indicate any Investment option, your funds wll be Invested In Auto Cholco (LC 50).
3. In case you hava opted for Auto Cholce and ill up secdion () below relating lo Asset Allocallon, the Assot Allocation instnucions will ba ignored and investment will

be made as por Auto Cholce (LC 50).

2 of 5
Yer 15

(lil) ACTIVE CSRF

CHOICE- ASSET ALLOCATION (to be filed up only in casa you have soloctod 'Actlvo
Cholco' tho invastmont optlon)
E c G - -

Asset Class (Cannot (Max up to (Max up to (Cannot Total Assel dass EEquity
and relaled instruments; Asset
exceed 75%) class CCorporate debl and related
100%) 100%) exceed 5%6)
instruments;Asset dass GGovement Bonds and |
related instruments; Asset
Specily % A-Ahenatve lnvesument Funds induding insruments like Class
CMBs, MBS, REITS, AIFs, Invts etc.
100%

Choices in
In case of Govemment
Gov sector Not available Avalable employee/sutbscriber the Acive choice of Asset Allocalion is restriaed to Asset
available
Class 'G only
Please note -

1. Upto 50 years of age, the maximum

permitted Equity Invesument ís 75% of the tolal asset allocation.
2. From 51 years and above, maximum
permitted Equily Investment will be as per the equity allocation matrix
allocation will be camied out as par the matrix on date of provided In Annexure A. The tapering off of equty
birth.
3. The tolal allocation across E, C, G and A asset
dassas musl be equal lo 100%. In case, the
allocation is left blank and/or
be rejocted.
does not equal 100%, the application shall
(v) AUTO CHOICE OPTION (to bo fillod up only In casa you havo soloctod tho 'Auto
a cholco of LC, Cholco' Invostmont optlon). In caso, you do not Indicato
your funds will be invostod as por LC 50.
Life Cydo (LC)
Funds
Please Tick () Choices in Go
Only One socdor Note: 1. LC 75-It is the Life
LC 75 oycle fund where the Cap to Equity investments is 75% of the tolal asset
Not available 2. LC 50-It is the Life
cyde fund where the Cap to Equity investments is 50% of the total asset
LC60 3. LC 25- It is the Ufo
cycle fund where the Cap to Equity investments is 25% of the total asset
Avallablo 4. Govt. employea can exercice Auto Choico of
LC 25 Asset Allocation for LC 25 & LC 50 only

11 DECLARATION ONFATCA (ForolgnAccount Tax ComplancoAct)

CoMPLIANCE (Ploaso refer to Srno.7 of tho instructions)
Section
US Person Yes No

Section II
For the purposes of
taxation, I am a resident in the following countries and
Out below or I have indicated that a my ldentification Number (TIN)/functional equivalent in. each
Tax
TIN/functional equivalant is unavailable (kindly fill details of all countries country is set
of tax residence if more than
one)
Particulars Country (1) Country (2) Country (3)
Country/countries of tax residency

Address Line 1
Address in the jurisdiction for Tax City/TownVillage
Residence
State

ZIPIPost Code
Tax identificalion Number
(TIN/Funcional equivalent Number
TINI
Functional equivalent Number Issuing Country
Valldity of documentary evidence provided (Wherever
applicable) dd/ mn / yyyy
I certity that: ioI mnl
a) It shall be my responsibility educate myself
to
and to comply at all
Rules, 1962 thereunder andtimes with all relevant laws relating to reporting under section 285BA of Act read with the
Rules 114F to 114H of the Income tax
b) the Information provided by me in the
Fom, its supporting
the
infomalion provided in the Fom is ln accordance with the aforesaidthe rules,
Annexures
corect and complate and that I have not withheld any matenal Infomatonwell as as ln the documentary evidence are, to the best of my
or otherwmse. that may affect the knowledge and belief, tue,
c) Ipemit/authorise the NPS Trust to
assassmentcategorizaion of the account as a
Reportable account
and any of NPS intermedlanies collect, store, communicate and process lnformation relating to the Account and all
wherever sltuated Induding shaning, transler and
disclosure
transactions therein, by the NPS Trust
confidential information for compliance with any law o regulation whether domastic between them and to the authorities in
andlor outside India of any
d)lundertake the responsibility to dedare
and disclose
or forelgn.
the Fom, Its
supporting Annexures wellas as In the
within 30 days from the date of change, any changes that may take place in the
cerlification along with documentary documentary evidenc8 provided by ma or il any cerification infomation provided in
becomes incorect and to
e) lalso agree that in case of my evidenca, provide fresh self-
designatedisbynotthe Govemmentfailure
of
to disclose any malerial fact known to me, now in
India the or future, the
NPS Trust may
report
purpose or take any other action as may be deemedto
remedied by me within (GO) IRBURDARFRDA regulator and/or any authorty
1or the any
deficiency
Ihereby accept and acknowledge that the süpuated pêniod. the appropriate by the NPS Trust if the
for contiming the NPS Trust
information provided by me to the NPS shall have right and authority to camry out investigations from the Information
9) I also agree to furnish such TTust avallable in public domain
information
abroad in the subject matter herein.
andor documents as the NPS Trust
may require from time to time on
h) Ishll lndemnlfy NPS Trust for any loss
account of any change in law either in
India or
that may arise to the NPS Trust on accOunt of providing Incomect or
incomplete Information.

Date
dd mm yy
Place :

Signature/Thumb Impresslon' of Subseriber In black ink

Name of subscriber LTI in case of male and RTI in case of femalas)

3 of 5
Ver 1.5 CSRE
12 DECLARAIONBYSUBSsCRIBER (Feore.erto.Stne.a(hensucbon)
Declaration å Authorization by all subscribers
I have read and understood the terms and condions of the National Pansion System and hereby agreetothe samo along withthe PFRDAACL,regulalions framed thereunder
and dedare that the infomaion and documents turmished by me are tnuo and cortect, to the best of myknowledgeand belie. undertake to infominmedatelythe Central
Record Keeping Agency/National Pension Systom Trust, of any change in the above infomation furnished by me. I do not hold any pre-edsing acount under NPS.
understand that I shall be fully liable for submission of any false or Incorrect Information or documents.

Ifurther agree to be bound by the terms and condions of provisian of servicas byCRA from time toime and any amendment therac as aproved by PFRDA, whether
compleleor parial wilhout any new dedaraion baing furmished by ma. I shall be bound by the terms and condions for tho usage of l-PIN (o access CRA websio and view
details) & T-PIN.
Declaration under the Provention of Money Laundering Act, 2002
Ithe
hereby decdare uhat the contnibution paid by melon my behaf has been dervedfrom iegaly dedaredand assessed sourcesofincoma undarstandthatNes Trust has
rignt to peruse my financal profile or share the intormalion, withotheargovemment authories. I turther agree that NPS Trust has the nght to dose my PRAN in casa l am
found violating the provislons of any law relating to preventlon of money laundering.

Date E L E 7
Placa
Signaturo/Thumb Improssion* of Subscrlber in black ink
(LTI in case of male and RTI in case offemales)

43. DECLARATION BYEMPLOYER

tARICEbIetO SoreromontSnbsclbors.only
(Subscribers Employmont Dotalls to bo fllod and attestod by the Doptt. (All Dotalls aro Mandatory)

Date of Joining Date of Retiremant 7 EEA

Employee Code/iD (lf applicabde) Emloyee Coden0 and PPAN are optional. I you intend
PPAN (If applicable) to provide, mention any one.
Group of Employee (Tick as applicable) Group AL Group B Group C D Group D
Office
Department
Ministry
DDO Registration Number
OTO/PAOICDDO/DTA/PtAO Registration Number
Basic Pay
Pay Scale
lt is certifed that the details provided in this sub6criber ragistralion form by. employed with us, induding
the address and employment details provided above are as per the servica record of the employee maintained by us. Also, it is further certified that
he/she has read entries/entries have been read over to him/her by us and got confmed by him/her

Signature of the Authoised peson Rubber Stamp of the DDO Signature of the Authorised person Rubber Stamp of the DTOIPAOICODO
(ln the box above) (In the box above) (In the box abovo)_ DTA/PAO (nthe box above)
Designation'of the Authorised Person
Designatlonofthe Authorised Person
Name of the DDO Name of DTOIPAOICDDOIDTANPAO

Dept/Ministry
74DECEARATION BYEMELOYERICOREORAVE s
EAPPCablotoig.orPoratg SubsSCTlbors.onN
(Subscribers Employment Details to be filled and attested by Corporate (All Details are Mandatory))

Date of Joining Date of Retirement

a
Employee Code/lD

Corporate Regd. Number (CHO No.)Alloted by CRA

cBO No. allotted by CRA

Certified that the delails provided in this subscriber registraltion fom by . employed with us, induding thee
employment details provided above are as per the service record of the employee maintained by us. Also, it is:further certified that he / she has read the
entries/ entries have been read over to him / her by us and got confrmed by him / her.

Place

Slgnature of the Authorised parson (n the box above)

Designation of the Authorised Person Rubber Stamp of the Corporate (In the box above)

4 of 5
Ver 1.5 CSRE

16DECLARATiONAYTHEAGCREGATOR RKE ALaa RE

hnAPplicaboioNPS.LIG Subscribers
Authorisation by Aggrogator's offico (NL -AO)
Certified that the subscriber is registered with the aggregator and he/she has opted to Join NPS. I hereby decdare that the subscriber is eliglble to Join NPS
and the above decdaration has been signed thumb Impressed before me by . . ***************************** ************** (s)he has raad the entries/ entries have
been read ovar to her/him by me.
**** *

Signatyre of the Authorisod person (In tha box abovo) Rubber Slamp of the Aggregator(ln Iho box above)
Name of the Aggregator

NPS Lie Account Ofice (NL-AO) Registralion Number IL NPS Lite-Colection Centre (NL -CC) Registralion Nurmber LL LU|
Membership No. alotted by Aggrogator (if any)
L LLLLU
Placa
Dale Lo oli|m|m|zZ
16 TOBEFILLED EY ROR SP
Receipt No. (17 digit) POPSP Registralon Number
mmmmarvtrumummmts

Document accepted for date of Birh Proof:

Copy of PAN card submited YES NO KYC Compliance YES No

Documents Received:
(Originals Verifed) Self Certifed (Attested) True Copies
ldentity Verification LDone
Existing Customor:
we hereby certify/confim that Shri/SmUKum. an existing KYC verified customer The above applicant is having an operative Bank
DematFolio/. . a ccount (specify nature of the account) having account number/dient ID.. maintalned at. branch/office.
The KYC documents available with us for this customer/dlient matches the requirement for opening NPS account and are in compliance with PMLA
RulesIWe further confim that the Savings Bank alcof Sh/SmUKum.. s not a "Basic Savings Bank Deposit Account (applicable in case of
Bank PoP)

To be fillad by POP-SP
Name:

Designation Place

POP-S Signature of Authorizad Signatory |Date

To be filled by CRA-Faclltation Centro (CRA-FC)]

*****

Received by CRA-FC Rogistration Number

Received al Dale

Acknowledgement Number (by CRA-FC)

PRAN Alloted
LLLLLLLU
************************************************************************** ***************"******* "***********

ACKNOWLEDGEMENT
Name of the Subscriber

Contribution Amount Remitted:

Date of Recoipl of Application and Contribution Amount:

d d a my ylyly]

Stamp and Signature of the Employer/POP:

5 of 5
Ver 1.5 CSRE
INSTRUCTIONS FOR FILLING THE SUBSCRIBER REGISTRATION FORM
Gonoral Guidolinos
(a) and
Please flthe fom in legible handwriting.so as to avoid ercorsinyour application processing. Pleaso do nat overwrite. Coredionsshoud temadabycanceling and rwating
such coroctions should be countersigned by the applicant. Each box, wherever provided, should contaln only one character (alphabel/ number / puncduaion mare) leang
a lank bOX after each word.
( I n case, you mention the KYC number submission of proof for the sameis necessary
t(). eThe
Appications incompleteinany respactandiarnal acompanied byrequred documents liabie to be rejocted. The apication is liablo to be rejected f mandatony fodds
i t blank or the application form is printed backto back
are

subscbershouldnot sign across the photograph,Thephotograph should not ba stapled or cliped to the form, If there is any mark on the photograph such tha t hindars
are

..the dear visibility of the faca of the subscriber, the application shall not ba accapted.
(o) Copias of all the documents submitted by the applicant should be sel-attested and accompanied by oniginals for venfication by the nodal offica.
DName and Address of the applicant menioned on the fom, shouid malch with the documentary proof submited.
/ Office.
9 n e subscnbers thumb's impression should be venfied by tha designated officer of POP-SP Nodal
S.Item Item Detalls Instructlons
No
Personal Details
This Formis applicableonlyfor Resident Indians. Thare is aseparale Formfor Non Resident Indians &Overseas Ctizenolndia
Currently, Foreign Nationals /Other Country Individuals (oC) and Persons ofIndian Origin(PIO)are
n oalc topen PRAN.
on PRAN Card.
shal menuon (athers nama and mothers name and shall seed the opuon to be pinted
. ne aPplicant
Spouse Name |f married,spouse name is mandatory.
Falher's Name aners name is mandatory.
Hfathers name hasmorathan 30 digits,you mayfll Annexurellfor the sane
Mother's Nama MOarsname ls mandatorythan 30
. f Mothers name has more digils, you may fill Annexure ll for the same.
Date ofBirth Pleaseensurethalthedate of birthmatches asIndicaledInthe document provided inthe support
S.No Proof ofldentity(Copy of any one) S.No Proof ofAddress (Copy of any one)-
1Passport issued by Government of india. Passport issued Dy Government of India
2 Rationcard with photograph. 23Bank
RalionPass
cardwith photograph and residantial addrass
book or certficate with pholograph and residental
3 Bank Pass book or certificate with Photograph.
address
4 Cerificale of the POPfor an oxistlngcuslome 4 Cerificate of the POPfor an existing customer.
5 Voters ldentilycard with photograph and rasidential addre9s.5 Voters ldentity card with photograph and residential address
6 Valid Driving license with photograpnn 6 Letter
Valid Driving license with pholograph and residenlial address
from any recognized Public authornty at the lavel of
7 Certificate of ldentity wilh pholograph signedby a Momber of
Parliament or Member of Legisltive Assembly Gazetted officerlike Distid Magistrate, Divisiona commissioner
BDO, Tehildar,
Cerificate
Mandal Revenue Officer, Judicial Magistraieelc
of address with photograph signed by a Member of
8 PAN Cardissued byIncome tax department Paniament or Member of Legisauve Assemby
9Aadhar Card /letterissued by Unique Idantificaion Authority
9Aadhar Card letter issued by Unique ldenification Authority o
Idenity, O lndia
ndia ceariy showing the address
Correspondenca &
Pemanent address 1 0Job cardsIssued by NREGA duly signed by an officer of tho 1 0 Jobcards Issued by NREGA duly signed by an oficer of the
detalls
Sare Govemment State Govemment
2 , 3&4
11 ldentity card issued by Cantra/State,government and its 11 The identity card/document with address or letter of allotment
Oaccomodation ssued by any of the following: Cera
Departments, Statutory/ Regulatory Authoritles, Pubic Secdor
Undertakings, Scheduled commercia Banks, Public Financial Stata Government and its DepartmentsStstutorRegulaon
Institutions, Colleges afliated touniversities and Prolessional
Bodies such as ICAl, ICWAI, ICSI, Bar Council elc.
Authorities, Public Sector Undertakings, Scheduled commercia
|Banks, Financial Institutions and listed companises for ther
employees.Pension or Family Pension Paymant Orders issued
by Gov. Departmanls or PSU containing'addrass
12 Photo. ldentity Card issued by Defence, Paramilitary and| 12 LatestElectrictywaterlpipad gas bill in the name ofthe Subscriber
Paice department's Claimant and showing the address (ess than 2 months od)
13 Ex-Service Man Card issued by Ministry of Defence to their 13 Lalest Telephone bill (landline& postpaid mobile) in the name of
the Subscriber/ claimant and showing the address (less than 2
employees. months okd)_
14 Photo Credit card. 14 Latest Property/house Tax receipt (not more than one year old)
15 Exising valid ragistered laase agreement of the housa on stamp
paper (in case of rentedieased accommodation)
Note:
0) fthe address on the document submitted for identity proof by the prospective customeris same as that declared by him/her in the account
Opening form, the document may be acoepted as a valid proof of boh identity and address.
) H the address indicated on the document submitted for idenüty proof dilifers from the current address mentipned in the account opening
form, a separate proofofaddress should be obtained. Allfuture communications will be sent to correspondence address. lf corespondehce
& Permanent addre5s are different, then proof for both have to be submitted.
(n) The KYCdocumenls maybesubmitted within a peñod of30 daysaftergeneration of PRAN. (Only for Govarnment Subscribers)
edPolitically Exposed PersonsREPS) are individualswho are or have been entrusted with prominent public
functions in a foreign country, for
Poincorose example heads ofstate orof thegovemment,sonior politicians, senior government, judiciel or military officials, senior executivas of state
wned corporations,importantpolitica party officialsS.
For Tierl& Tierll account, bank detalsare mandatory and t shoudd be supported by a documentary proof. Please attach a cancelled cheque
Subscrbers Bank containing Subsciber Name, Bank Name, Bank Account Number and IFS Code. H cheque is not available or cheque is not preprinted with
Details Subscriber name, a copy of bank passbook or bank siatement or bank cerüficata or letter from Bank mentioning Subscriber Name, Bank
Name, Bank Account No. and FS Code shoud be submilted.
In case of more than onenominee, parcantage share value for al the nominees must be integer. Decimals/Fracional values shall not be
Subscribers
Nomination Details 0 0 n nw prceage share across al the nomine6s must bo equal to 100. If sum of percentage is not equal to
Nomination Detals 100, entire nomunaion wl DB TG d
Pension Fund (PF)Sovemment employeelsubscnbers can exercice chaice o Penslon Funds and allocate their investments eitherin Asset ClassG under
0 Selection and ACice Choiceand Ine ycaPunds or Li5underAutoChoice.in case a dovemment employeelsubscibers does not exercises
h e choices of Penslon Fundher contnbuuonswube allocaled among 03 Pension Funds namely () LIC Penslon Fund Limited (ü) sBI|
Investment OptionPa
Ponsion Funds Py. Umited ()9T Reurementsoluions Ltd.
|Clarficalion/ Guidelinason filling details if agplicant residenca for tax purposes in jurisdicion(s) outside India
urisdicions) of 1axResidence:Since Us taxes the global income of fts citzen, every US ctizen of whatever nationality, is alsoa resident

Taxldentification NumberTIN):TIN need no be reporedi t has not been issued by the jurisdiction. However, if the sald jurisdiction has
1
Decaratlon by
subscriber on FATCAA Sof tna type
on nagnynuoe vanveoenicauonauncional equlvalentthe same may be reported. Examples
c nuberforncdndual incude, a socal secunity/ins urance number, clizen/personal identification/servicas code/numberand
Compliance
f apolicantresidence for tax purpose In Juísdicion(s) within India, Pemanent Account Number 1De
(PAN) to be provided
provided as Tax ldentfication
as Tax ldentfication Number
Number (TIN
(TIN) |
In case applicant is decdaing US person siatus as 'Norelinquishmentbut hisher Cont Gvdenang Reinquishment ol
Cilizenshlp should be provided or reasons for not having cerifcate is 1o anrd
Dcarauon Dy designated officer of pOPIPOP-SP/Nodalotice with the oficien e o humb impression, if used, should ba attested by th8
2 Decdaration by desianated officar of POPIPOP-SP/Nodal olfice with the official seal and stamp. Left Thumb Impression in case of maes and Right Thumb
Subscriber Impression In case of females.
General Informatlonfor Subscrlbers
a) The Subscriber can obtain the status of his/her application from CRA and their designated nodal officer.
b) Subscrbers are advised to retain the
acknowiodgement sip slgned stampad by the designaled nodal officer where they submit the application.
)For more inlormation/ dailications, contac CRA:

Website: httos://www.ngscra.nsd.Lco.in
Call: 0224090 4242
Addre3s:CentralRecordkeeping Agengy (CRA
NSDL-Governanca lhfrastructure umite
1st Floor, Times Tower,Kamala Mills Compound, Senapall Bapat Marg.
LowerPared (W), Mumbaí 400013
Yer 1.5

Annexure Ato CSR

Equity Allocation Matrix for Active Choice

Age (years) Max. Equity Allocation

Upto 50 75%
72.50%
52
70%
53 67.50%
54
65%
55
62.50%
56
60%
57
7.50%
58
55%
59
52.50%
60 & above
50%

Please nole:
Upto 50 years of age, the maximum
parmitted Equily lnvestment is 75% of the total asset
From 51
years and above, maximum allocation.
allocation will be caried out as pemitled Equity lnvestment will be as per the
per the matrix on date of birth. equity allocation malrix provided above. The tapering off of equity
 sQUTHCENTRALRAILWAY
GUNTAKAL DIVISION
New Pension System
(Delails to be furnished by the Railway Servant)

01 Name of Railway Servant

02 Designation

03 Name of Ministry, Departmen

Organisation
04. Scale of pay

05. Date of Birth

06 Date of joining Senvice

07. P.F.No./P.Pan

08. Admn. Unit / Bill Unit

09 Pay

10 Nominee for accumulations underthe

Pension Account

Age / Date of Percentage of Relati-onship

.No. Name of Nominee (s) with the Railway
Birth Share Payable |
Servant

Signature of the Railway Servant

YrnetmKeiox, orlGY MS

Scanned by CamScanner
 ACS. No. :
SOUTH CENTRAL RAILWAY
Guntakal Division
Nomination for Provident Fund, CGISand Death cum Retirement Gratuity

Department Station:
Provident Fund No. Unit

1, Sri/Smt. hereby direct that the amount at my credit

in my Account of the State Railway Provident Fund, any amount that may be sanctloned by the Central Government under the
the Govermment in the event
Central Government Employees Group Insurance Scheme 1980, any Gratuity that may be sanctioned by
which become admissible to m e on retirement and remain
of my Death while in Service and the right to receive any gratuity having
unpaid at my death may be paid to the following nominees.
Name, address and
Contigencies on
rclationship of the person, if
Amount or the happening
any on whom the right of the
Name and Address of he Nominees' Age of of which shall
share to be nominee is conserred in the
nomince or nominees Rclationship nominee
paid to each
become invalid
event of his predeceasing the
subscriber
subscriber

1. Provident Fund:

2. CGIS:

3. DCRG:

earlier which stands cancelled.

the nomination made by me on
This nomination supersedes

day or
Dated this
under CCIS' and DCRG are member/members ofmy family
Note: The nominees for receipt ofamount

Witness to Signature

. Signature of the Railway Servant.

Date