RAILWAY RECRUITMENT CELL, EAST COAST RAILWAY

APPLICATION FORM ( in A4 size paper )

E.N. No.ECoR/RRC/D/2012 dated 31.07.2012

Read the Employment Notification carefully before filling up the application form: 1. Name of the candidate (in capital letters):

For office use only

letters):

2. Fathers/ Husbands name (in capital Paste your latest

passport size photograph

(4cm x 5cm)
3. Nearest Railway Station: 4. Full address for correspondence: 5. Sex: 6. Nationality: 7. Religion: State Contact Phone No. with STD Code: 9. Date of Birth: Date PIN Month Year 8. Marital Status: 10. Tick ( ) Community :

UR

OBC

SC

ST

11. Educational Qualification tick ( ) the appropriate column: SSC/Matric HSC/SSC ITI Diploma Non Technical Graduate Post Graduate Technical Graduate Post Graduate

12. Choice of language for Written Examination (English/Hindi/Urdu/Oriya/Telugu):

13 Tick ( ) appropriate column, if applicable. (Enclose copy of certificate in support of claim) Persons with Disabilities VH HH OH Widow / Divorced / Judicially separated Economically Weaker Section Serving Railway Employees Central / State Govt. Employees Staff of Quasi Administrative offices of Railways Residents of Jammu & Kashmir

14. Write two visible Marks of Identification (Moles etc.):

1. 2.

15. Details of IPO/DD No.____________________ Date: ________________ Amount: _________ Name of the Post office / Bank _______________________ 16. Put two specimen signatures below (Do not sign in capital letters): 17. Put two Left Thumb Impressions below(Must be clear and not smudged): 1. Specimen Signature 2. Specimen Signature 1. Left Thumb Impression 2. Left Thumb Impression

18. DECLARATION BY THE CANDIDATE (Please reproduce the paragraph in your own running handwriting in the space given below): I hereby declare that all the particulars given above by me are true and correct to the best of my knowledge and belief. In the event of any information being found false, my candidature / appointment is liable to be cancelled / terminated. _________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ 19. Place : 20. Date: _____________________________________________ 21. Signature of the candidate (Do not sign in capital letters)