Declaration Form for pass, PTO & Complimentary Pass

Declaration Form for pass, PTO & Complimentary Pass – For serving Railway employees/ pensioners/ family pensioners

_________________ 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 : ______

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 :

12. Attached photographs of above family members / dependent members as per pass rules.

13. Address : ______________________________________________________________________

______________________________________________________________________

_______________________________________ Pin Code : ______________________

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)