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1 SOUTH WESTERN RAILWAY RAILWAY RECRUITMENT CELL, HUBLI APPLICATION FORM FOR RECRUITMENT AGAINST EX-SERVICEMEN QUOTA (Application form must be submitted in a good quality, A-4 size plain white paper, using one side only. Candidate should fill up the required information in his/her own handwriting only) Ref: Employment Notice No.01/2013 dated Name of the Candidate : (Write Name followed by initials in CAPITAL letters) 2. Father s/husband s Name : (Write Name followed by initials in CAPITAL letters) 3. Nearest Railway Station : 4. Address for communication : PIN CODE (Optional) : Telephone No. with STD Code: (Optional) : Mobile No. 4.1 Permanent Address : PIN CODE Affix here your recent passport size photograph not older than one month. Specimen Signature 5. Date of Birth : Date: Month: Year 6. Sex(Write Male (or) Female): 7. Nationality : 8. Marital Status : (Write single (or) married) 9. Religion : 10. Community : (Only SC/ST/OBC Ex-servicemen need to enclose (Write UR or OBC or SC or ST) self attested Photostat copy of Community certificate) (The SC/ST candidate shall keep one attested copy of valid Community certificate to be produced along with free travel authority to the Ticket Checking Official on demand.) 11. Particulars of Military service: (Enclose self attested Photostat copy of Discharge Certificate) Indicate the Service (Write Army (or) Navy (or) Air Force) Rank held in Military service Military service Number Date of Enrolment Date of Attestation Date of Discharge Total Service Years Months Days Reasons for Discharge

2 12. Zila Sainik Board/Employment Exchange Registration No. (if registered) 13. Write your two personal marks of identification 1) 2) 14. Qualification SSLC HSC/PUC/Intermediate Act Apprenticeship/ITI Diploma Graduation Post Graduation Other Qualification, if any Military Qualification Month & Year of passing School/Board/ University Percentage of marks(up to two decimals) The following declaration has to be written by the candidate in his/her own handwriting in the space provided below: DECLARATION I hereby declare that all the particulars given in this application are true and correct to the best of my knowledge and belief. In the event of any information being found false or incorrect or being not eligible in term of eligibility criteria, my candidature/appointment is liable to be cancelled/terminated without any notice at any stage. (Signature of the candidate) Name: LTI of the candidate Date: Place:

3 ANNEXURE I FORM OF CASTE CERTIFICATE FOR SC/ST CANIDATES APPLYING FOR APPOINTMENT TO POSTS UNDER THE GOVERNMENT OF INDIA. This is to certify that Shri/Smt./Kum Son/Daughter of of village/town District/ Division of State/Union Territory belongs to the Caste/Tribe which is recognized as Scheduled Caste/Scheduled Tribe under: The Constitution (Scheduled Caste) order, The Constitution (Scheduled Tribe) order, The Constitution (Scheduled Caste) (Union Territory) order, The Constitution (Scheduled Tribe) (Union Territory) order, 1951 (as amended by the Scheduled Caste and Scheduled Tribe Lists Modification) Order 1956, the Bombay Reorganization Act 1960, the Punjab Reorganization Act, 1966, the State of Himachal Pradesh Act, 1970, the North Eastern Areas Reorganization Act, 1971 and the Scheduled Tribes Order (Amendment Act, 1976). The Constitution (Jammu & Kashmir) Scheduled Caste Order, The Constitution (Jammu & Kashmir) Scheduled Tribes Order, The Constitution (Andaman and Nicobar Islands) Scheduled Tribes Order, The Constitution (Dadra and Nagar Haveli) Scheduled Caste Order, The Constitution (Dadra and Nagar Haveli) Scheduled Tribes Order, The Constitution (Pondicherry) Scheduled Caste Order, The Constitution Scheduled (Uttar Pradesh)Tribes Order, The Constitution (Goa, Daman and Diu) Scheduled Caste Order, The Constitution (Goa, Daman and Diu) Scheduled Tribes Order, The Constitution (Nagaland) Scheduled Tribes Order, The Constitution (Sikkim) Scheduled Caste Order, The Constitution (Sikkim) Scheduled Tribes Order, Shri/Smt./Kum.* and/or his/her* family reside (s) is Village/Town of District/Division* of the State/Union Territory of Signature Designation (with seal of office) State/Union territory. Place: Date: (*) Please delete the words which are not applicable. Note: The term* Ordinarily resides* used here will have the same meaning as in Section 20 of the Representation of the Peoples Act, (**) Officers competent to issue Caste/Tribe certificates: ** District Magistrate/Additional District Magistrate/Collector/Deputy Commissioner/Additional Deputy Commissioner/Deputy Collector/1st Class stipendiary Magistrate/City Magistrate/Sub- Divisional Magistrate/Taluka Magistrate//Executive Magistrate//Extra Assistant Commissioner (not below the rank of 1st Class stipendiary Magistrate)/Chief Presidency Magistrate/Additional Chief Presidency Magistrate/ Revenue Officers not below the rank of Tahsildar/Sub-Divisional Officer of the area where the candidate and/or his/her family reside (s). Note: ST Candidates belonging to Tamilnadu State should submit caste certificate ONLY from the REVENUE DIVISIONAL OFFICER.

4 FORM OF CERTIFICATE FOR OTHER BACKWARD CLASS CANDIDATES ANNEXURE II This is to certify that Shri/Smt./Kum* Son/Daughter* of of village District/Division* in State belongs to the Community which is recognized as a backward class under: Resolution No.12011/68/93-BCC(C) dated 10th September 1993, published in the Gazette of India Extraordinary- part 1 Section 1, No.186 dated 13th September, Resolution No.12011/9/94-BCC dated 19th October 1994, published in the Gazette of India Extraordinary- part 1 Section 1, No.163 dated 20th, October Resolution No.12011/7/95-BCC dated 24th May 1995, published in the Gazette of India Extraordinary- part 1 Section 1, No.88 dated 25th, May Resolution No.12011/44/96-BCC dated 6th December 1996, published in the Gazette of India Extraordinary- part 1 Section 1, No.210 dated 11h, December Resolution No.12011/68/93-BCC published in the Gazette of India Extraordinary No.129 dated 8th July, Resolution No.12011/12/96-BCC published in the Gazette of India Extraordinary No.164 dated 1st Sep., Resolution No.12011/99/94-BCC published in the Gazette of India Extraordinary No.236 dated 11th Dec., Resolution No.12011/13/97-BCC published in the Gazette of India Extraordinary No.239 dated 3rd Dec., Resolution No.12011/12/96-BCC published in the Gazette of India Extraordinary No.166 dated 3rd Aug., Resolution No.12011/68/93-BCC published in the Gazette of India Extraordinary No.171 dated 6th Aug., Resolution No.12011/68/98-BCC published in the Gazette of India Extraordinary No.241 dated 27th Oct., Resolution No.12011/88/98-BCC published in the Gazette of India Extraordinary No.270 dated 6th Dec., Resolution No.12011/36/99-BCC published in the Gazette of India Extraordinary No.71 dated 4th April, Shri/Smt./Kum.* and/or his/her* family ordinarily reside (s) in the District/Division* of the State. This is also to certify that he/she does not belong to the persons/sections (Creamy Layer) mentioned in column 3 of the Schedule to the Government of India, Department of Personnel and Training O.M. No.36012/22/93-Estt. (SCT) dated 8/9/1993 and modified vide Government of India Department of Personnel and Training O.M. No.36033/32004-Estt. (Res.) dated Date: Seal: District Magistrate/ Dy. Commissioner etc.. Note: The terms* Ordinarily used here will have the same meaning as in Section 20 the Representation of the Peoples Act

5 ANNEXURE III Proforma for declaration to be submitted by Other Backward Class Candidates along with the application while applying for the posts against Employment Notice No.01/2013 dated of RRC/S.W.Rly. DECLARATION I Son/Daughter of Shri resident of Village/Town/City District State hereby declare that I belong to the (indicate your sub-caste) community which is recognized as a backward class by the Government of India for the purpose of reservation in services as per orders contained in Department of Personnel and Training Office Memorandum No.36012/22/93-(SCT) dated It is also declared that I do not belong to persons/sections (Creamy Layer) mentioned in column 3 of the Schedule to the above referred Office Memorandum dated and its subsequent amendment through O.M.No.36033/3/2004 Estt. (Res.) dated Place: Date: Signature of the Candidate Name of the Candidate

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