Application Form

First Name *

Middle Name

Last Name *

Father's Name / Mothers Name*

Date Of Birth *

Date Of Appointment *

Pay Band + GP*

Level* Select Level L1 L2 L3 L4 L5 L6 L7

Last pay drawn*

Date Of Retirement *

Retired from the department* Select Department ELECTRICAL GENERAL ELECTRICAL TRS,ELS,Loco Shed GZB ELECTRICAL EMU CAR SHED ELECTRICAL CHG. OPERATING MECHINCAL C AND W MECHINCAL DSL /Shed MECHINCAL POWER CIVIL Engineering Personnel ACCOUNTS S AND T COMMERCIAL MEDICAL Sr DME/Trainset Depot/SSB

Last Post in which you have worked.* Select Post

Retirement due to* Select Retirement due to Superannuation VR Compulsory

PPO Number *

Education Qualification *

D&AR History in which penalty if any* NO Minor Major Both (Minor & Major)

Medical category fit at the time of retirement* Select medical category A2 A3 B1 B2 C1 C2

Medical history / Any handicap* Select medical history NO Minor Surgical Any major disease

Safety / accident related history last 3 yers* NO YES

Have you ever been arrested/prosecuted?* NO YES

Have you ever been convicted by a court* NO YES

Bank Name & Address *

Account Number*

IFSC Code*

Address 1*

Address 2*

Tahsil*

District*

State*

Pincode*

Mobile Number *

Alternative Mobile Number *

E-Mail *

Award, if any (MR / GM / PHOD / DRM)*
  MR   GM   PHOD   DRM

Next

Upload Document

Photo

Signature

PPO

Submit

* Document size must be less than 1 MB.

* Document must be in JPG format.