ÇòêðÂð ÙðÏÚð Ü÷âðãð÷ Ñððçð ¨÷î òâ𦠡ðãð÷ÇÐð Ñðëð ¸ðóÑðó GP - 1 ÇòêðÂð ÙðÏÚð Ü÷âðãð÷ Ñððçð ¨÷î òâð¦

¸ðóÑðó GP - 1 ÇòêðÂð ÙðÏÚð Ü÷âðãð÷ Ñððçð ¨÷î òâ𦠡ðãð÷ÇÐð Ñðëð ¸ðóÑðó GP - 1
South Central Railway Application for Passes ¸ðó.G.302 ¦Òî F & ãð ¸ðó G.38 ¦Òî F South Central Railway Application for Passes ¸ðó.G.302 ¦Òî F & ãð ¸ðó G.38 ¦Òî F
Ñðöæ¿ çðü Page No…….. Ñðöæ¿ çðü Page No……..
(Úðè ¡ðãð÷ÇÐð Ñðëð Ñððçð µððèÐð÷ ¨îð÷ ÃððÜó®ð 7 òÇÐð Ñðõãðá Ñððçð ¸ððÜó ¨îÜÐð÷ ãððâð÷ ¨îðÚððáâðÚð Ùð÷ü Ñðèôµð ¸ððÐðð Úððòè¦) (Úðè ¡ðãð÷ÇÐð Ñðëð Ñððçð µððèÐð÷ ¨îð÷ ÃððÜó®ð 7 òÇÐð Ñðõãðá Ñððçð ¸ððÜó ¨îÜÐð÷ ãððâð÷ ¨îðÚððáâðÚð Ùð÷ü Ñðèôµð ¸ððÐðð Úððòè¦)
(This application should reach the Pass issuing office at least 7 days before the passes are required for use) (This application should reach the Pass issuing office at least 7 days before the passes are required for use)
òãðØðð±ð Department :……………………………………………………... ¨îðÚððáâðÚð Office………………………... òãðØðð±ð Department :……………………………………………………... ¨îðÚððáâðÚð Office………………………...

¡ÑðÐðó / ýÃðÜ Ü÷âðãð÷ ÑðÜ…………………..…….å÷Âðó ¨÷î ç¨õîâð çðõòãð³ðð ÙððÐðð¦ü Ñððçð ¨÷î òâ𦠡ðãð÷ÇÐð Ñðëð| ¡ÑðÐðó / ýÃðÜ Ü÷âðãð÷ ÑðÜ…………………..…….å÷Âðó ¨÷î ç¨õîâð çðõòãð³ðð ÙððÐðð¦ü Ñððçð ¨÷î òâ𦠡ðãð÷ÇÐð Ñðëð|
IA IA
Application for …………….....…….. Class / School/Privilege / Complimentary Passes over Home / Foreign lines. Application for …………….....…….. Class / School/Privilege / Complimentary Passes over Home / Foreign lines.

1. ÐððÙð Name of applicant: ………………………………..……………. ò¾¨î¾ Ððü. Ticket No……………………… 1. ÐððÙð Name of applicant: ………………………………..……………. ò¾¨î¾ Ððü. Ticket No………………………
2. ÑðÇÐððÙð 3. òÐðÚðôò©Ãð ¨îó ÃððÜó®ð 4. ãð÷ÃðÐð ÇÜ 2. ÑðÇÐððÙð 3. òÐðÚðôò©Ãð ¨îó ÃððÜó®ð 4. ãð÷ÃðÐð ÇÜ
Designation : ……………………….. Date of Appointment: ……………............ Rate of Pay : …………………. Designation : ……………………….. Date of Appointment: ……………............ Rate of Pay : ………………….
5. (¨î) Üð¸ðÑðòëð çðüãð±ðá Ùð÷ü Ñßãð÷äð ¨îó ÃððÜó®ð (®ð) çð÷ãððòÐðãðöòÄð ¨îó ÃððÜó®ð 5. (¨î) Üð¸ðÑðòëð çðüãð±ðá Ùð÷ü Ñßãð÷äð ¨îó ÃððÜó®ð (®ð) çð÷ãððòÐðãðöòÄð ¨îó ÃððÜó®ð
(a) Date of entry into Gazetted Cadre………………………(b) Date of Retirement : …………………………… (a) Date of entry into Gazetted Cadre………………………(b) Date of Retirement : ……………………………

(±ð) ÙðøÐð÷ ¡Øðó Ãð¨î ¡ÑðÐðó Ü÷âðãð÷ ÑðÜ Ñððçð ¨÷î……………………………. çð÷¾ð÷ü ¨îð £ÑðÚðð÷±ð ò¨îÚðð èøïü| (±ð) ÙðøÐð÷ ¡Øðó Ãð¨î ¡ÑðÐðó Ü÷âðãð÷ ÑðÜ Ñððçð ¨÷î……………………………. çð÷¾ð÷ü ¨îð £ÑðÚðð÷±ð ò¨îÚðð èøïü|
(c) I have so far availed ………………………………………………………………………………Sets of passes. (c) I have so far availed ………………………………………………………………………………Sets of passes.

×ððèÜó Úððëðð Outward Journey ãððÑðçðó Úððëðð Return Journey ×ððèÜó Úððëðð Outward Journey ãððÑðçðó Úððëðð Return Journey
6. From……………………………………….……….. çð÷ 10. From ………………………….……. çð÷ 6. From……………………………………….……….. çð÷ 10. From ………………………….……. çð÷
To…………………………………………………...Ãð¨î To…………………………………...……………..Ãð¨î To…………………………………………………...Ãð¨î To…………………………………...……………..Ãð¨î
Via………………………………………………...èð÷¨îÜ Via………………………….…………………...èð¨îÜ Via………………………………………………...èð÷¨îÜ Via………………………….…………………...èð¨îÜ
7. Break journey at ……………………………………….. 11. Break journey at…………………………………….. 7. Break journey at ……………………………………….. 11. Break journey at……………………………………..
………………………………………….ÑðÜ Úððëðð òãðÜðÙð ……..…………………………….ÑðÜ Úððëðð òãðÜðÙð ………………………………………….ÑðÜ Úððëðð òãðÜðÙð ……..…………………………….ÑðÜ Úððëðð òãðÜðÙð
8. £Ñðâð×Ïð òÇÐððü¨î Available from……………………. çð÷ 12.£Ñðâð×Ïð òÇÐððü¨î Available from……………...…. çð÷ 8. £Ñðâð×Ïð òÇÐððü¨î Available from……………………. çð÷ 12.£Ñðâð×Ïð òÇÐððü¨î Available from……………...…. çð÷
9. ãÚðò©Ãð ò¸ðÐð¨÷î òâð¦ Ñððçð µððòè¦ 13. ãÚðò©Ãð ò¸ðÐð¨÷î òâð¦ Ñððçð µððòè¦ 9. ãÚðò©Ãð ò¸ðÐð¨÷î òâð¦ Ñððçð µððòè¦ 13. ãÚðò©Ãð ò¸ðÐð¨÷î òâð¦ Ñððçð µððòè¦
Persons for whom pass is required Persons for whom pass is required Persons for whom pass is required Persons for whom pass is required
(¨î) çãðüÚð (a) Self (¨î) çãðüÚð (a) Self (¨î) çãðüÚð (a) Self (¨î) çãðüÚð (a) Self
(®ð) ÑðòÜãððÜ ¨÷î çðÇçÚð ¡ðÚðô ¡ðøÜ ¸ðÐÙð òÃðòÆð * (®ð) ÑðòÜãððÜ ¨÷î çðÇçÚð ¡ðÚðô ¡ðøÜ ¸ðÐÙð òÃðòÆð * (®ð) ÑðòÜãððÜ ¨÷î çðÇçÚð ¡ðÚðô ¡ðøÜ ¸ðÐÙð òÃðòÆð * (®ð) ÑðòÜãððÜ ¨÷î çðÇçÚð ¡ðÚðô ¡ðøÜ ¸ðÐÙð òÃðòÆð *
(b) Family Members Age & Date of birth* (b) Family Members Age & Date of birth* (b) Family Members Age & Date of birth* (b) Family Members Age & Date of birth*
(i) ………………………………………………………. (i) ………………………….………………………. (i) ………………………………………………………. (i) ………………………….……………………….
(ii) ………………………………………………..….…. (ii) …………………………………………………. (ii) ………………………………………………..….…. (ii) ………………………………………………….
(iii) ………………………………………..……………. (iii) …………………………………………………. (iii) ………………………………………..……………. (iii) ………………………………………………….
(iv) ……………………………………..………………. (iv) …………………………………………………. (iv) ……………………………………..………………. (iv) ………………………………………………….

(±ð) ¡ðòåÃð çðü×ðüÏðó ¡ðÚðô ¡ðøÜ ¸ðÐÙð òÃðòÆð + (±ð) ¡ðòåÃð çðü×ðüÏðó ¡ðÚðô ¡ðøÜ ¸ðÐÙð òÃðòÆð + (±ð) ¡ðòåÃð çðü×ðüÏðó ¡ðÚðô ¡ðøÜ ¸ðÐÙð òÃðòÆð + (±ð) ¡ðòåÃð çðü×ðüÏðó ¡ðÚðô ¡ðøÜ ¸ðÐÙð òÃðòÆð +
(b) Dependent relatives Age & Date of birth+ (b) Dependent relatives Age & Date of birth+ (b) Dependent relatives Age & Date of birth+ (b) Dependent relatives Age & Date of birth+
(i) ………………………………………………………. (i) ………………………….………………………. (i) ………………………………………………………. (i) ………………………….……………………….
(ii) ………………………………………………..….…. (ii) …………………………………………………. (ii) ………………………………………………..….…. (ii) ………………………………………………….
___________________________________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________________________________

+ +
ÚðòÇ ÙððÃðð òãðÏðãðð èð÷ Ãðð÷ òâðò®ðÚð÷ òãðÏðãðð ¨îð ¡òãðãððòèÃð ×ðèÐð ¡ðøÜ 21 ãðæðá çð÷ ¨îÙð ¡ðÚðô ¨÷î Øððýá ¨÷î ÙððÙðâð÷ Ùð÷ü ÚðòÇ ÙððÃðð òãðÏðãðð èð÷ Ãðð÷ òâðò®ðÚð÷ òãðÏðãðð ¨îð ¡òãðãððòèÃð ×ðèÐð ¡ðøÜ 21 ãðæðá çð÷ ¨îÙð ¡ðÚðô ¨÷î Øððýá ¨÷î ÙððÙðâð÷ Ùð÷ü
Úðè Øðó òâð®ðÚð÷ ò¨î ©Úðð òÑðÃðð ¸ðóòãðÃð èø| Úðè Øðó òâð®ðÚð÷ ò¨î ©Úðð òÑðÃðð ¸ðóòãðÃð èø|
+ +
State in case of mother if widow, In case of sister if widow or Unmarried and of brother if under 21 years; State in case of mother if widow, In case of sister if widow or Unmarried and of brother if under 21 years;
Also state whether father is alive or not. Also state whether father is alive or not.
* çðØðó ¨÷î ÙððÙðâð÷ Ùð÷ü ¡ðÚðô òâð®ðó ¸ððÐðó µððòè¦| * The age should be given in all cases. * çðØðó ¨÷î ÙððÙðâð÷ Ùð÷ü ¡ðÚðô òâð®ðó ¸ððÐðó µððòè¦| * The age should be given in all cases.
14. Ùðøïü ÑßÙððòÂðÃð ¨îÜÃðð èõü ò¨î Ñððçð Ùð÷ü äðòÙðâð ò¨îÚð÷ ¸ððÐð÷ ãððâð÷ ¡òåÃð çðÙ×ðÏðð÷ Ùð÷Ü÷ ³ðÜ ¨÷î ãððçÃðòãð¨î çðÇçÚð èøïü, 14. Ùðøïü ÑßÙððòÂðÃð ¨îÜÃðð èõü ò¨î Ñððçð Ùð÷ü äðòÙðâð ò¨îÚð÷ ¸ððÐð÷ ãððâð÷ ¡òåÃð çðÙ×ðÏðð÷ Ùð÷Ü÷ ³ðÜ ¨÷î ãððçÃðòãð¨î çðÇçÚð èøïü,
¸ðóòãð¨îð ¨÷î òâð¦ ÑðõÂðá ÝÑð çð÷ Ùðô»ðÑðÜ ¡ðòåÃð èø. Ùð÷Ü÷ çððÆð ÜèÃð÷ èøïü ÃðÆðð Ùð÷Üð / Ùð÷Üó ¨îð÷ýá Øððýá / ×ðèÐð £ÑðÚðôá©Ãð ¸ðóòãð¨îð ¨÷î òâð¦ ÑðõÂðá ÝÑð çð÷ Ùðô»ðÑðÜ ¡ðòåÃð èø. Ùð÷Ü÷ çððÆð ÜèÃð÷ èøïü ÃðÆðð Ùð÷Üð / Ùð÷Üó ¨îð÷ýá Øððýá / ×ðèÐð £ÑðÚðôá©Ãð
¡ðòåÃðð÷ü ¨÷î òâð¦ Ñððçð Ððèó âð÷Ãðð / âðð÷Ãðó èøïü| ¡ðòåÃðð÷ü ¨÷î òâð¦ Ñððçð Ððèó âð÷Ãðð / âðð÷Ãðó èøïü|

I certify that the Dependent relatives to be included in the pass are actual members of my household, I certify that the Dependent relatives to be included in the pass are actual members of my household,
entirely dependent on me for their means of subsistence and residing with me and no brother / sister of entirely dependent on me for their means of subsistence and residing with me and no brother / sister of
mine is obtaining pass for the above dependents. mine is obtaining pass for the above dependents.

15. Ñððçð ¨÷î ±ðâðÃð Áü±ð çð÷ £ÑðÚðð÷±ð ¨îÜÃð÷ ÑðÜ òÙðâðÐð÷ ãððâð÷ ÇüÀð÷ü çð÷ Ùðøïü ÑðòÜòãðÃð èõü| 15. Ñððçð ¨÷î ±ðâðÃð Áü±ð çð÷ £ÑðÚðð÷±ð ¨îÜÃð÷ ÑðÜ òÙðâðÐð÷ ãððâð÷ ÇüÀð÷ü çð÷ Ùðøïü ÑðòÜòãðÃð èõü|
I am aware of the penalties to which I am liable for the misuse of passes. I am aware of the penalties to which I am liable for the misuse of passes.

16. Ùð÷Ü÷……..………..….ãðæðóáÚð ………..……….¨îð òãðÌððâð¦ / ÙðèðòãðÌððâðÚð ¨îð ÑßÙððÂðÑðëð âð±ððÚðð èõü| 16. Ùð÷Ü÷……..………..….ãðæðóáÚð ………..……….¨îð òãðÌððâð¦ / ÙðèðòãðÌððâðÚð ¨îð ÑßÙððÂðÑðëð âð±ððÚðð èõü|

ç¾üäðÐð Station: ……………………… ç¾üäðÐð Station: ………………………

¡ðãð÷Ç¨î ¨÷î èçðÃððêðÜ Úðð ×ðð¦ü èðÆð ¨÷î ¡ü±ðô¿÷ ¨îð òÐðäððÐð ¡ðãð÷Ç¨î ¨÷î èçðÃððêðÜ Úðð ×ðð¦ü èðÆð ¨÷î ¡ü±ðô¿÷ ¨îð òÐðäððÐð
òÇÐððü¨î Dated : ………………….…… Signature of L.T.I of application òÇÐððü¨î Dated : ………………….…… Signature of L.T.I of application

Ððü. No. ……..…òÇÐððü¨î Dated : ……………….…20 ¸ððüµð ò¨îÚðð ………………… å÷Âðó ¨îð Ñððçð Ððü. No. ……..…òÇÐððü¨î Dated : ……………….…20 ¸ððüµð ò¨îÚðð ………………… å÷Âðó ¨îð Ñððçð
…………………………….î¨îð÷ ¡ÐðôÑððâðÐð èÆðá Ñß÷òæðÃð| ò¸ðÐð¨÷î òâð¦÷ ¡ðãð÷ÇÐð ò¨îÚðð ±ðÚðð èø|¡Ððôäð÷Úð èø| …………………………….î¨îð÷ ¡ÐðôÑððâðÐð èÆðá Ñß÷òæðÃð| ò¸ðÐð¨÷î òâð¦÷ ¡ðãð÷ÇÐð ò¨îÚðð ±ðÚðð èø|¡Ððôäð÷Úð èø|
£ÑðÚðôá©Ãð òãðãðÜÂð ¨îó òãðòÏðãðÃð ¸ðüðµð ¨îÜ âðó ±ðÚðó èøïü| èçÃððêðÜ Signature:. …………………………….. £ÑðÚðôá©Ãð òãðãðÜÂð ¨îó òãðòÏðãðÃð ¸ðüðµð ¨îÜ âðó ±ðÚðó èøïü| èçÃððêðÜ Signature:. ……………………………..
¡ðãð÷ÇÐð Ðð÷ ýçð ãðæðá ………........¡ÑðÐðó Ü÷âðãð÷ ÑðÇÐððÙð Designation:. …………………………….. ¡ðãð÷ÇÐð Ðð÷ ýçð ãðæðá ………........¡ÑðÐðó Ü÷âðãð÷ ÑðÇÐððÙð Designation:. ……………………………..
……….………..ýÃðÜ Ü÷âðãð÷ ¨÷î çðôòãðÏðð / ç¨õîâð / çãðó¨öîÃð Sanctioned:. …………………………….. ……….………..ýÃðÜ Ü÷âðãð÷ ¨÷î çðôòãðÏðð / ç¨õîâð / çãðó¨öîÃð Sanctioned:. ……………………………..
ãððÐððæðá Ñððçð òâðÚð÷ èø| ÃðÆðð £Ðð¨îó òÇÐðü¨î ……... çð÷ èçÃððêðÜ Signature:. …………………………….. ãððÐððæðá Ñððçð òâðÚð÷ èø| ÃðÆðð £Ðð¨îó òÇÐðü¨î ……... çð÷ èçÃððêðÜ Signature:. ……………………………..
……………...Ãð¨î ¨îó ¶ô¾öó çãðó¨öîÃð ¨îó ±ðÚðó èøïü| ÑðÇÐððÙð Designation:. ………………………….. ……………...Ãð¨î ¨îó ¶ô¾öó çãðó¨öîÃð ¨îó ±ðÚðó èøïü| ÑðÇÐððÙð Designation:. …………………………..
Forwarded to ……………………………………for òÇÐððü¨î ……………………..…….….. 20 Forwarded to ……………………………………for òÇÐððü¨î ……………………..…….….. 20
complaints. The above entries have been duly ……….….…… åüÂðó ¨îð Ñððçð çðü®Úðð ……….… complaints. The above entries have been duly ……….….…… åüÂðó ¨îð Ñððçð çðü®Úðð ……….…
checked. The application has taken ………. Local checked. The application has taken ………. Local
òÇÐððü¨î ……...… Üò¸ðç¾Ü çðü®Úðð ……….....¨÷î òÇÐððü¨î ……...… Üò¸ðç¾Ü çðü®Úðð ……….....¨÷î
……………………..Foreign sets of Privilege School/ ……………………..Foreign sets of Privilege School/
……………Ñðöæ¿ ÑðÜ Ñððçð âð÷Ðð÷ Ùð÷ü Ǹðá çðÏÚðð¨öîÃð| ……………Ñðöæ¿ ÑðÜ Ñððçð âð÷Ðð÷ Ùð÷ü Ǹðá çðÏÚðð¨öîÃð|
Complimentary passes during the current year and Complimentary passes during the current year and
Date…………………………………………………. 20 Date…………………………………………………. 20
has been sanctioned leave from …………………… Pass No……………………………….. Date………… has been sanctioned leave from …………………… Pass No……………………………….. Date…………
entered in the pass account in page………………… entered in the pass account in page…………………
to …………………. to ………………….
of Register No……………………….………. attested. of Register No……………………….………. attested.
¨îðÚððáâðÚð Office:...........… ç¾÷äðÐð Station………….. ¨îðÚððáâðÚð Office:...........… ç¾÷äðÐð Station…………..
èçÃððêðÜ Signature:. …………………………….. ……………. ……………… èçÃððêðÜ Signature:. …………………………….. ……………. ………………
ÑðÇÐððÙð Designation:…………………………….. ¡ÌððêðÜ Initials èçÃððêðÜ Signature ÑðÇÐððÙð Designation:…………………………….. ¡ÌððêðÜ Initials èçÃððêðÜ Signature

çðü No………………………………òÇÐððü¨î Dated……………………………20 çðü No………………………………òÇÐððü¨î Dated……………………………20

………………… å÷Âðó ¨îð Ñððçð çðü Class Pass No……………….. òÇÐððü¨î Dated……… ¸ððÜó ò¨îÚðð ±ðÚðð Issued ………………… å÷Âðó ¨îð Ñððçð çðü Class Pass No……………….. òÇÐððü¨î Dated……… ¸ððÜó ò¨îÚðð ±ðÚðð Issued

ç¾÷äðÐð Station:…………………………… ………………………………………………………….. ç¾÷äðÐð Station:…………………………… …………………………………………………………..

¡ðãð÷Ç¨î ¨÷î èçÃððêðÜ Úðð ×ðð¦ü èðÆð ¨÷î ¡ü±ðô¿÷ ¨îð òÐðäððÐð ¡ðãð÷Ç¨î ¨÷î èçÃððêðÜ Úðð ×ðð¦ü èðÆð ¨÷î ¡ü±ðô¿÷ ¨îð òÐðäððÐð
òÇÐððü¨î Dated : …………………….…… Signature of L.T.I of applicant òÇÐððü¨î Dated : …………………….…… Signature of L.T.I of applicant
_________________________________________________________________________________________ _________________________________________________________________________________________
äð×Çð÷ü Ùð÷ü òâðò®ðÚð÷ ±ðâðÃð òµðÐè Ðð âð±ððýÚð÷ To be filled in words and not by cross market. äð×Çð÷ü Ùð÷ü òâðò®ðÚð÷ ±ðâðÃð òµðÐè Ðð âð±ððýÚð÷ To be filled in words and not by cross market.