RAIL WHEEL PLANT, BELA

(Indian Railways)

APPLICATION FORM FOR POST-RETIREMENT COMPLIMENTARY PASS

1. Name (in BLOCK letters) :.....................................................

2. Last Designation : Retired

3. Last pay drawn : Rs.................................

4. Class of pass eligible IA/I/IIA/II Class:.................

5. Date of Birth: / / .

6. Date of appointment : / /

7. Date of retirement: / /

8. Pass required –From ................................ To ........................ and back via.............................

9. Break journey :...............................................................................................................

10. Pass applied for : Self,

11. Number of passes availed during the year. ............

12. If so, Pass No. and date :

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I declare that the passes applied for person/persons other than self is/are solely dependent on
me.

Signature of the Retired Employee

Address:

Station:
Date :
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(for Office use only)