Annexure-1

RAILWAY RECRUITMENT BOARD

Roll No. (For official use only)

Control No: (for office use)

APPLICATION FORM FOR Employment Notice No ...../2011

PLEASE FILL UP THE APPLICATION IN CAPITAL LETTERS IN OWN HANDWRITING.

Signature should not be in Capital letters.

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

1.

CATEGORY No. & POST

(for single category)

Cat. No

Name of Post

2. Choice of Railway :
(Wherever applicable)

Paste (do not pin or staple) here your colour passport size photographof size 4cm x 5cm (The colour photograph should not be more than 3 months old) Not to be attested
3
rd

st

nd

Signature of candidate in the box below the photograph

3. NAME OF CANDIDATE 4. COMMUNITY(Tick ) 5. FATHERS NAME: 6. DATE OF BIRTH(DD/MM/YYYY)

8. Qualification (Fill in only those qualifications prescribed for the post/s applied for)
(A) Academic SSC/X/Matric Higher Secondary/Inter Graduation Post Graduation Others (B) Technical I.T.I/Apprentice Diploma Engineering Degree Others Qualification University/Board Year of passing Discipline / Trade Marks % Qualification University/Board Year of passing Subjects Marks %

UR

OBC

SC ST

7. AGE AS ON 01-07-2012 years months days

9. ADDRESS
(FOR CORRESPONDENCE)

PIN CODE

10.

ARE YOU (i) Govt. Employee Yes/No

(ii) Ex-serviceman

Yes/No

(iii) Physically Challenged

Yes/No

VH

HH

OH

11. Present employment (To be filled by all Railway/Central/State/PSU employees) Designation & Grade Name & address of Employer Date to Date from 12. Ex-servicman (Ex-SM) Date of Attestation Date of Enrolment

Date of Discharge

Length of Service

Left Hand Thumb Impression of Candidate in this box

Note: 1) Candidates must fill up their name, fathers name &date of birth as indicated in their matriculation certificate. 2) Candidates should put their full signature at all the places in the same language (in English or in Hindi).

Signature of the Candidate

Annexure-2

RAILWAY RECRUITMENT BOARD,

INFORMATION SHEET (For Centralised Employment Notice No..../2011)

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

1. NAME OF CANDIDATE
2. Tick( )Gender Female
Male

Marital Status Married Unmarried

3. Nationality

4. Permanent address :

State 5. NEAREST RAILWAY STATION

(For issue of free Railway pass to SC / ST candidates)

PIN Code

6. VISIBLE MARK OF IDENTIFICATION ON BODY

To be filled compulsory

7. Medium of Examination (Choose any one of the regional Languages of concerned RRB as mentioned in Sr. No. 15)
8 (a) Details of Postal Orders / Demand Drafts (DD) enclosed
NAME OF POST OFFICE / BANK SERIAL NO. AND DATE AMOUNT

8 (b) Do you seek fees exemption

( ) TICK appropriate box

SC ST PWD Female Candidate Ex - SM Minority community

MUSLIM CHRISTIAN SIKH BUDDHIST JAIN

Economically Backward Classes (Ref. Annexure: 8)

PARSI OTHERS

9.

RELIGION: HINDU

10. Do you seek age relaxation

( ) TICK appropriate box

SC ST OBC

Railway Course Completed Judicially separated/ PWD J & K divorced woman / widow Resident Ex - SM Employee Act Apprentice a) No b) For 2 years c) For life
Self Declaration from OBC candidates as per Annexure-5 Disability Certificate (for PWD as per Annexure:9)

11. 12.

Whether you were debarred by any RRB in the past

Document attached in proof of: Indicate by (
Community Certificate
(for SC/STOBC)

) Tick mark in the relevant boxes indicated below

Discharge Certificate
(For Ex-Serviceman)

IPO/DD

Qualification Certificate

Matric/SSLC Certificate
(for DOB Proof)

Declaration from Visually handicapped Candidates as per Annexure: 10 Income Certificate for Economically Backward class Certificate (As per Annexure-7)

Self Declaration of Minority Community (As per Annexure-8)

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 I shall also be liable for any other action under the extant rules

Place: Date:

Left Hand Thumb Impression of Candidate in this box

Signature of the candidate