App Reg No: (for official use) एक ट अध न यम 1961 क तहत एक ट प रश क ष क र प म भत ह क श ए आव द फ मम APPLICATION FORM FOR ENGAGEMENT OF ACT APPRENTICE UN

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11 App Reg No: (for official use) एक ट अध न यम 1961 क तहत एक ट प रश क ष क र प म भत ह क श ए आव द फ मम APPLICATION FORM FOR ENGAGEMENT OF ACT APPRENTICE UNDER THE ACT APPRENTICE ACT 1961 (Ref: Combined Notification No:1/2017/Act App/CW/PER Dated:15/06/2017 ) अभ यर थ क म Name of the Candidate: पपत /म त /पनत क म/ Father/Mother/Husband Name: यदद पपत /म त /पनत र व म ह If Father/Mother/Husband in Railways, यदद ह त पववरण द / If so furnish details: स व रत Serving स व -न व त त Retired Deceased Affix a recent passport size photo To be attested by Gazetted Officer दट. /कममच र / T.No/Emp No पद म / Designation प/पवभ ग/म ड /क य म य Shop/Dept/Div/Office 4 5 पत Postal Address जन म क त र ख Date of Birth र ज य/State पप क ड/ Pincode: श ग/Gender प रष / Male स त र / Female 6 सम द य/ Community UR OBC SC ST क य अक षम व यक क त ह? Whether Person with Disability (Physically Handicapped) आ र क डम Adhaar Card No: र जग र क यम य प ज कर बरर Employment Exchange Registration Number य ग यत Qualification ITI Certificate Std.X Std.XII (for MLT) उत त णम क र गर /ब डम Trade Passed/Board CBSE/State Board CBSE/State Board प र प त क Marks Secured Visual Hearing Orthopaedic 10. म ब इ. Mobile No: क आ ब दटत अ क Total Marks allotted प रनत तत Percentage (Engineering Degree/Diploma holders are not eligible to apply) 11. क र गर क चय / Choice of Trade: A: For ITI s: Name of Institution Trade From To Year of passing B: For Fresher s: (Indicate choice of Trade in the space provided) 1 st 2 nd 3 rd 4 th 5 th 6 th C: For Medical Lab Technician: Radiology Pathology Cardiology 12: आव द क स र थ स ग प रम ण-पर क पववरण ज र जपत ररत अध क र द व र सत य पपत ह / Copies of Certificates enclosed with the application, duly attested by a Gazetted officer (Please tick) (Relevant certificates should be valid on the date of notification) A. Std XII/X/Mark Sheet D. ITI Certificate from NCVT G. Transfer Certificate B. Proof of Date of Birth E. ITI trade Mark List H. Emp.Exchange Card C. Disability Certificate F. Community Certifiate I. Adhaar Card

12 13 प स त ट आडमर / Postal Order No: त र ख / Date यदद छ ट ह त क रण Otherwise Exemption due to SC ST PWD Female 14 म एतत द व र घ पषत करत ह कक जह तक म र ज क र ह, ऊपर उक ल खखत पववरण सत य ह यदद ग त ह त म र अक भ यर थ रद द क ज सकत ह /म र प रश क ष प तत क सम प त कर द ज सकत ह I herby declare that the above particulars are true to the best of my knowledge, and if found to be false, my candidature could be cancelled/my apprenticeship could be terminated forthwith. स त र थ /Place: त र ख/Date: ब ए अ ग ठ छ प Left thumb Impression आव दक क हस त त क षर / Signature of the applicant (Signature in capital letters are not allowed) Certification ( for wards of serving Railway employees) This is to certify that Mr./Mrs.. Father/Mother/Husband of Shri/Smt/Kum...is working as.. in.. Date: Signature of the Supervisor : Office Seal Name : Note:- The wards of serving Railway employees should get the above certification from their immediate supervisor. In case of wards of Retired/Deceased Railway employees, the attested copy of service certificate should be enclosed. SC/ST/Wards of Railway Employee Candidates need not enclose copy of Employment Registration Card Check list (Office use only) 1. Application is in the prescribed format Yes No 2. Attested Photo is pasted Yes No 3. Candidate Signed /Affix Left thumb impression in the Application form Yes No 4. Proof enclosed for Date of Birth Yes No 5. Community (Proof enclosed) UR SC ST OBC 6. Wards of Serving Railway employees (Certified by Supervisor) Yes No Wards of Retired/Deceased Railway employees (Service certificate enclosed) Yes No 7. Proof enclosed for employment registration (Except Wards of Railway Employee/SC/ST) Yes No 8. Qualification Fresher Ex-ITI Academic - X std (Proof enclosed) Yes No Technical ITI - (Proof enclosed) Yes No 9. Physically challenged (Proof enclosed) Yes No 10. Postal order (Rs.100/-) enclosed (Except/SC/ST/PWD/Female) Yes No 11. Aggregate mark in 50% above Yes No If so Whether Under Aged Over aged Suitable Age Eligible or Ineligible Committee member 1 Committee member 2 Committee member 3

13 FORM OF CASTE CERTIFICATE FOR SC/ST ANNEXURE - II (The Form of the certificate to be produced by Scheduled Castes & Scheduled Tribes candidates applying for appointment to posts under the Govt. of India) This is to certify that Shri/Smt./Kum* Son/Daughter* of.of Village/Town*.. in District /Division * of State/ Union Territory*.. belongs to the. Caste / Tribe* which is recognized as a Scheduled Caste / Scheduled Tribe * under : The Constitution (Scheduled Castes) Order 1950*. The Constitution (Scheduled Tribes) Order 1950*. The Constitution (Scheduled Castes) (Union Territories) Order1951* The Constitution (Scheduled Tribes) (Union Territories) Order 1951* (As amended by the Scheduled Castes and Scheduled Tribes Lists (Modification) Order, 1956, the Bombay Reorganization Act 1960, the Punjab Re-organization Act, 1966, the State of Himachal Pradesh Act,1970, and the North Eastern Area Re-organization Act, 1971, and Scheduled castes & the Scheduled Tribes Order (Amendment Act, 1976). The Constitution (Jammu and Kashmir) Scheduled Caste Order 1956@. The Constitution (Andaman and Nicobar Island) Scheduled Tribes Order 1959@ as amended by the Scheduled Castes and Scheduled Tribes order (Amendment Act.) 1976@ The Constitution (Dadra and Nagar Haveli) Scheduled Castes Order, The Constitution (Dadra and Nagar Haveli) Scheduled Tribes Order, 1962@. The Constitution (Pondicherry) Scheduled Castes Order, 1964@. The Constitution Scheduled Tribes (Uttar Pradesh) Order, 1967@ The Constitution (Goa, Daman and Diu) Scheduled Castes Order,1968@. The Constitution (Goa, Daman and Diu) Scheduled Tribes Order, 1968@. The Constitution (Nagaland) Scheduled Tribes Order, 1970@. The Constitution (Sikkim) Scheduled Castes Order, 1978@. The Constitution (Sikkim) Scheduled Tribes Order, 1978@. Shri/Smt/Kum*... And / or his/her* family ordinarily reside(s) in 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 Please quote specific Presidential Order. Note : i) The term *Ordinarily reside(s)** used 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/ 1 st 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/Presidency Magistrate/Revenue Officers not below the rank of Tahsildar. / Sub Divisional Officer of the area where the candidate and / or his /her family normally reside(s). Note: ST candidates belong to Tamilnadu State should submit caste certificate ONLY from the REVENUE DIVISIONAL OFFICER.

14 OBC CERTIFICATE FORMAT Annexure - III FORM OF CERTIFICATE TO BE PRODUCED BY OTHER BACKWARD CLASSES APPLYING FOR APPOINTMENT TO POST UNDER THE GOVERNMENT OF INDIA. This is to certify that Shri/Smt/Kum*... Son/Daughter* of Shri of Village /Town... District... in... State belongs to... community which is recognized as backward class under (indicate the Sub Caste above) 1. Resolution No /68/93-BCC@dtd 10th September 1993, published in the Gazette of India- Extraordinary Part-I, Section 1. No. 186 dated 13th September Resolution No /9/94-BCC dated 19th October 1994, published in the Gazette of India- Extraordinary Part-I, Section I. No. 163, dated 20th October Resolution No /7/95-BCC dtd 24th May 1995, Published in the Gazette of India- Extraordinary Part-I, Section I. No. 88 dtd 25th May Resolution No /44/96-BCC dtd 6th December 1996, published in the Gazette of India- Extraordinary Part-I, Section I. No. 210, dated 11th December Resolution No /68/93-BCC, Published in Gazette of India Extra Ordinary No. 129, dated the 8th July Resolution No /12/96-BCC, Published in Gazette of India Extra Ordinary No. 164 dated the 1st Sept Resolution No /99/94-BCC, Published in Gazette of India Extra Ordinary No. 236 dated the 11th Dec Resolution No /13/97-BCC, Published in Gazette of India Extra Ordinary No. 239 dated the 3rd Dec Resolution No /12/96-BCC, Published in Gazette of India Extra Ordinary No. 166 dated the 3rd August Resolution No /68/93-BCC, Published in Gazette of India Extra Ordinary No. 171 dated the 6th August Resolution No /68/98-BCC, Published in Gazette of India Extra Ordinary No. 241 dated the 27th Oct Resolution No /88/98-BCC, Published in Gazette of India Extra Ordinary No. 270 dated the 6th Dec Resolution No /36/99-BCC, Published in Gazette of India Extra Ordinary No. 71 dated the 4th April Shri/Smt/Kum*... and / or his/her family ordinarily reside(s) in the... District 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 /22/93/Estt. (SCT) dated ) and modified vide Government of India, Department of Personnel and Training O.M. No /3/2004/Estt.(RES). dated Place: Date: (with seal of office)

15 ANNEXURE -IV Proforma for declaration to be submitted by Other Backward Class Candidates along with the application while applying for the posts against Employment Notice No. of RRB. 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-Estt.(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 through O.M. No.36033/3/2004-Estt.(Res.) dated Place: Date: Signature of the Candidate Name of the candidate