APPLICATION FORM

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RAILWAY RECRUITMENT BOARD, MUMBAI, RAILWAY DIVISIONAL OFFICE COMPOUND

MUMBAI CENTRAL, MUMBAI - 400202 APPLICATION FORM
(All applications must be submitted in A4 size 65-70 GSM paper)

E.N. NO. CEN-03-2012 Control No:(for office use) .............. PASTE(do NOT pin or staple) here your recent colour passport size Photograph of size 3.5 cm X 3.5 cm (The colour photograph should not be more than 3 months old) Not to be Attested

I SUBMIT MY APPLICATION FOR THE FOLLOWING CATEGORIES 1. Category No I 7 V 0 2. NAME OF POST II VI 2 0 TRAFFIC APPRENTICE III IV III 0 IV 0

ASSISTANT I STATION II MASTER V VI II WR

3. CHOICE OF RAILWAY

I CR

III SCR

(Give in preference order i.e. CR, WR, SCR)

4. EXAMINATION MEDIUM 5. NAME 6. DATE OF BIRTH 7. FATHERS NAME 8. AGE 9. GENDER 10. RELIGION 11. COMMUNITY 12. ADDRESS

ENGLISH JITENDRA PALIYE (DD/MM/YYYY) 17-11-1985

........................ Signature of the candidate in the above box below the photograph (NOT in capitals)

SUBHASH DURGADATTA PALIYE 26 Years,7 Months,14 Days male hindu UR JITENDRA PALIYE, PO: WCL COLONY UMRED MQ/258 City : NAGPUR District : NAGPUR State : MAHARASHTRA Pincode : 441204

13. NEAREST RAILWAY STN 14. RELIGION 15. IDENTIFICATION MARKS

NAGPUR hindu MOLE ON LEFT FOOT SOLE

16. (i) GOVT EMPLOYEE No (ii) EX SERVICEMAN No (iii) Physically Handicapped No if Physically Handicapped 17. DETAILS OF IPO / DD NAME OF POST OFFICE/BANK WCL Waigaon Umred SERIAL NO. AND DATE 54G475470,00F616197 AMOUNT 50.00 LEFT THUMB IMPRESSION

SPECIMEN SIGNATURES i)............................................... ii)............................................... iii)...............................................

18. DOCUMENTS ATTACHED IN PROOF OF : INDICATE BY TICK MARK Matric/SSLC Qualification Certificate Qualification Certificate if IPO/DD (for DOB Certificate any(For Proof) Ex-Serviceman) Self Disability Declaration Certificate From No Objection Self Declaration From (For Minority Certificate(For OBC candidate as per Physically Community serving Govt./PSU annexure-5 Handicapped candidate as employees) as per per annexure-9) annexure-8

Discharge Certificate (For Ex-Serviceman)

community certificate(for SC/ST/OBC)

Economically Backward Certificate (Should be in the letter head of the issuing authority as per Annexure-7)

I HEAREBY DECLARE THAT THE ABOVE INFORMATION IS TRUE TO THE BEST OF MY KNOWLEDGE
........................................................... SIGNATURE OF THE CANDIDATE (SPECIMEN SIGNATURE IN BLOCK LETTERS SHALL DISQUALIFY THE CANDIDATE) (ALL SIGNATURES IN THE APPLICATION FORM SHOULD BE IDENTICAL)

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APPLICATION FORM

http://www.rrbmumbai.gov.in/ApplicationFormsNew/printform.php

RRB/Mumbai-Information Sheet (for E. N. No. 01-2008 (BCT) )

(All applications must be submitted in A4 size 65-70 GSM paper) 1. NAME 2. Date of Birth 3. Marital Status 4. Nationality 5. PERMANENT ADDRESS JITENDRA PALIYE 17-11-1985 unmarried INDIAN JITENDRA PALIYE, PO: WCL COLONY UMRED MQ/258 City : NAGPUR District : NAGPUR State : MAHARASHTRA Pincode : 441204

(A) Academic SSC/X/Matric

Qualification SSC

University/Board Year Of Passing

Higher Secondary/XII /Inter B) Technical Diploma Engineering Degree Others

HSSC Qualification

Subjects MARATHI HINDI NAGPUR ENGLISH MAHARASHTRA 2001 SCIENCE MATHS BOARD SOCIAL SCIENCE HINDI ENGLISH NAGPUR MATHS PHYSICS MAHARASHTRA 2003 CHEMISTRY BOARD BIOLOGY University/Board Year Of Passing Subjects

Marks(%) 74.26

58.33 Marks(%) -

B.Sc

RTM NAGPUR UNIVERSITY

2009

PHYSICS CHEMISTRY MATHS

45.70

7. Present Employement (to be filled by all Railway/Central/State/PSU Employees) Experience (Designation & Grade if Applicable) Date From Date To Name & Address of the Employer

8. Ex-Servicemen (Ex-SM) Date of Enrolment Date of attestation Date of Discharge Length of Service 0.00 9. Are You Seking Fee Exemption no no J&K resident Railway Employee Course Completed Act Apprentice

10.Whether you were debarred by any RRB in the past 11. Do you seek age relaxation if yes TICK in the Judicially Separated/divorced women

SC ST OBC

ExS

PWD

relevant box 12.Declaration: I hereby declare that I have carefully gone through the eligibility criteria for the post applied for and meet all the conditions therein; that all the statements made by me in the application are true and complete to the best of my knowledge and brief and nothing has been concealed or suppressed. I also understand that in case, any of my statements is found untrue during any stage of recruitment or thereafter shall disqualify me for the post applied for and/or I shall be liable for any other action under the extant rules (Above para to be written by the candidate in his/her running hand writing in English below) ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________

........................................................... Place : ................................... Date : ................................... Left Thumb impression of Candidate SIGNATURE OF THE CANDIDATE

For Details please read Employment Notice

Online Registration No : CEN-03-2012-33497

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