Annexure-I

To APPLICATION FORM The Assistant Personnel Officer (Rectt) Employment Notice South Eastern Railway ,Bungalow 12 A No-SER/RRC/OM/01/2013 11 Garden Reach Road,Kolkata-700 043 Recruitment in Pay Band-I Rs.5200-20200/- with GP Rs.1800/(UR, SC, ST, OBC and PWD) on South Eastern Railway

1

FOR OFFICE USE ONLY

Name of Candidate:

Paste(do not pin or staple) here your recent colour passport size photo of size 4.5cm X 3.25cm (The colour photo shall not be more than one months old) Not to be attested.

(IN BLOCK LETTER)

2

Father’s /Husband’s Name:

3

(IN BLOCK LETTER) Nearest Railway Station

4

Address for Communication: ( IN BLOCK LETTER)

PIN CODE NO 9

Date of Birth

11

Community

13

D

D

M

M

Order of preference (Category No. upto 5 preference)

14 SSLC/MATRIC

1st

Y

2nd

Y

Y

3rd

Y

4th

5

Sex:

6

Nationality:

7

Religion:

8

Marital Status:

Signature of the Candidate

10

Persons with Disability Disability Percentage (%) Whether Scribe required (YES/NO)

12

Age Relaxation

5th

Educational Qualification, tick (
) the appropriate column HSC/SSC ITI DIPLOMA NON-TECHNICAL GRADUATE POST GRADUATE

15 17

Serving Employee (Yes/No) Fee Exemption (Yes/No)

16 18

19

Personal marks of identification (Mole,cut mark etc in the body)

1 2

20

Name of the post office/Bank & Place

GRADUATE

TECHNICAL POST GRADUATE

If yes, indicate the organisation Choice of Language for Examination

Details of IPO/DD enclosed with the AF Serial No Date

Amount

21. Declaration by the candidate :(Copy the passage in the box below in your running hand writing): Not required to write by Blind/Cerebral Palsy Candidates who needs the assistance of scribe. “I hereby declare that all the particulars given above by me are true, complete and correct to the best of my knowledge and belief. I am aware that in the event of any information furnished by me is found false / incorrect at any stage, my candidature / service will be rejected / terminated summarily and I am also liable to criminal action. I will abide by the instructions given in the notification”.

Place:

Date:

Left Thumb Impression

Signature of the Candidate