Format of Declaration Form for pass, PTO & Complimentary Pass to be submitted by all Railway Employees & Pensioners every year

Format of Declaration Form for pass, PTO & Complimentary Pass to be submitted by all Railway Employees & Pensioners every year

Format of Declaration Form for pass, PTO & Complimentary Pass to be submitted by all Railway Employees & Pensioners every year
_________________ Railway ___________________ Division/Workshop/Unit
DECLARATION FORM FOR ALL TYPES OF PASSES
(For serving employees/pensioner/ family pensioner – including widow
passes)
To,
DRM(E) ______________________
CWM ________________________
_____________________________
My Service particulars of is as under for declaration of passes:
1. Name of Employee/ Pensioner / Family Pensioner :
_____________________________________
2. Designation of Employee / Pensioner : ____________________
Department : ________________
3. Basic Pay / Pension / Family Pension :
________________________________________________
4. Grade Pay / Level : __________________ Pay band / Scale :
______________________________
5. Present / Last working station : ___________________ Working under :
_____________________
6. Basic Pension on retirement : _________________________ Last Basic
Pay : ________________
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7. PPO Number : __________________________________________ Dated
___________________
8. Date of Appointment :__________________________ Date of Retirement
: __________________
9. Date of death of pensioner (in case of family pensioner) :
_________________________________
10. Post retirement pass identity card No. : _________________ issued
by : ____________________
11. Details of family / dependent members :
Sr. No.
Name
Relation
Date of birth
Identification marks
01
02
03
04
05
06
12. Attached photographs of above family members / dependent members as per
pass rules.
13. Address : ______________________________________________________________________
                      ______________________________________________________________________
                      _______________________________________ Pin Code :
______________________
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                     Contact Number : (M) ________________________ (LL)
_______________________

UNDERTAKING CERTIFICATE:

I the undersigned is certify that above information is correct as per my
best knowledge & any information hides may lies to DAR action.
Yours faithfully,
Signature/thumb impression of Applicant .
Name of Applicant (_______________________)

Encl: 1. PPO 2. Pass identity card 3. Photos 4. Money Receipt for widow
pass (whichever applicable)

Declaration-Form-for-Pass-PTO-&-Complimentary-Pass

Click here to download Form in PDF / Editable Word format

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