Declaration Form for pass, PTO & Complimentary Pass to be submitted by all Railway Employees & Pensioners every year

_________________ 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) 

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