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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 :
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 : ______________________
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)

Click here to download Declaration Form for pass, PTO & Complimentary Pass

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