Annexure 1

Application for Recruitment in Pay Band-1 of ` 5200-20200/- + Grade Pay ` 1800/- in South East Central Railway
Employment Notice Number SECR/02/2010 For office use only:

1. Name of the Candidate

2. Fathers Name

: Paste (do not pin or staple) here your recent colour passport size photo of size 4 cm x 5 cm (The photograph shall not be more than three months old)

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

: SC VH Yes ST OBC HH No 8. 9. 10. PIN 11. Signature of the Applicant Nationality Religion Sex Marital Status UR OH

4. Community ( Put ):

5. Are you physically disabled ( Put ): 6. Are you Ex-Serviceman ( Put ): 7. Address for Communication :

12. Nearest Railway Station (In English) 13. Visible Marks of Identification (Moles etc.) : 1. 2.

: .........................................................

14. Do you seek age relaxation under any of the category mentioned below? ( Put Tick in the appropriate box) : SC ST OBC Physically Course Completed Judicially separated/ ExDisabled Act Apprentice Divorced Woman/Widow Serviceman 15. Educational Qualifications (Tick in the appropriate column)

Railway Employee

SSLC/Matric

HSC/Inter

ITI/Apprentice

Other Higher Qualifications

16. List of documents enclosed (Fill in the details of the copies of documents/certificates enclosed) : 1. 2. 3. 4. 5. 18. Declaration by the Candidate (Copy the passage in the box below in your own handwriting failing which application will be rejected) : I hereby declare that all the particulars given above by me are true and to the best of my knowledge. I am aware that in the event of any information furnished by me is found false/incorrect at any stage; my candidature will be rejected summarily and I am also liable for criminal action. I will abide by the instructions given in the above employment notification. 17. Details of IPO/Demand Draft enclosed with the application : Name of the Post Office/Bank Serial Number & Date Amount in `

Place: Date: Left Thumb Impression Signature of the Applicant