APPLICATION FORM FOR GRANT OF SCHOLARSHIP FOR HIGHER EDUCATION FOR GIRL/MALE CHILDS OF GROUP ‘D’ RAILWAY EMPLOYEES WORKING IN GRADE PAY OF RS.1800/- FOR THE YEAR ……………. UNDER THE AEGIS OF STAFF BENEFIT FUND, ALD. ---------------------------------------------------------------------------------------- a. Particulars of the Employee

1. Name of the Employee _______________________________

(In Block Letters)

2. Designation _______________________________

3. Station of posting & Sr.Sub. _______________________________

Under whom working _______________________________

4. Mobile No./DOT No. _______________________________

5. Whether SC/ST _______________________________

6. Date of Appointment _______________________________

7. Pay Scale & Grade Pay _______________________________

8. Rate of Pay _______________________________

b. Particulars of Child

1. Name of the Child _______________________________

2. Date of Birth _______________________________

3. Name of the Degree/Diploma _______________________________

4. Duration of Degree/Diploma _______________________________

5. Name of the Institution in which student _______________________________

Is studying & state in which situated _______________________________

6. Is the Institution recognized by the _______________________________

Govt. or affiliated to a University, pl. state _______________________________

7. Name of Bank & Place _______________________________

8. Bank Account No.: _______________________________

9. IFSC CODE ______________________ MICR CODE ___________________

c. School Record of the Girl/Male Child S.No. Name of the Qualified

Examinations on basis of which

admission taken

Year in

which

passes

Total Marks

obtained

Division in which

passes/Grade obtained

Percentage of

Marks

obtained

1 Matriculation/High School

2 Senior Secondary/10+2

3

4

Dated: ________ Signature of the Employee ____________________

Signature & Stamp of the Sr.Subordinate

NORT CENTRAL RAILWAY

DECLARATION

I hereby declare that my daughter/son for whom application is being submitted is not in

receipt of any stipend or assistance from any other source. I also give an undertaking that in case any

stipend or assistance is granted to her/him, subsequent to the grant of scholarship now applied for,

this will be immediately brought to the notice of the Chairman, Divl. Sub. Committee, Staff Benefit

Fund, Allahabad (Sr.DPO/ALD). I also declare that if my daughter/son fails to pass any examination

held in the institution where is studying, I will immediately supply this information to the Chairman,

Divl. Sub. Committee, Staff Benefit Fund, Allahabad (Sr.DPO/ALD).

I ALSO HEREBY DECLARE THAT I AM WORKING IN GRADE PAY OF RS.1800/-.

Signature of the Employee ____________________

Name of the Employee ____________________

Desg./Stat ____________________

CERTIFICATE FROM IMMEDIATE OFFICER

I have gone through the application and certify that the information given by the employee is

correct. It is also certified that the said employee is working in Grade Pay of Rs.1800/-.

Seal & Signature of the Immediate Subordinate/Officer

Certificates to be attached

1. Attested copy of the Matriculation/Secondary/10+2 certificate & mark sheet of the student.

2. A certificate on Prescribed Performa from the Head of the Institution where the student is

studying.

NORTH CENTRAL RAILWAY APPLICATION FORM FOR GRANT OF TECHNICAL SCHOLARSHIP FOR HIGHER EDUCATION FOR WARDS OF RAILWAY EMPLOYEES FOR THE YEAR ………………………. UNDER THE AEGIS OF STAFF BENEFIT FUND, ALLAHABAD. a. Particulars of the Employee

1. Name of the Employee _______________________________

(In Block Letters)

2. Designation _______________________________

3. Station of posting & Sr.Sub. _______________________________

Under whom working _______________________________

4. Mobile No./DOT No. _______________________________

5. Whether SC/ST _______________________________

6. Date of Appointment _______________________________

7. Pay Scale & Grade Pay _______________________________

8. Rate of Pay _______________________________

9. Name of Bank & Place _______________________________

10. Bank Account No.: _______________________________

11. IFSC CODE ______________________ MICR CODE ___________________

b. Particulars of Child

1. Name of the Child _______________________________

2. Date of Birth _______________________________

3. Name of the Degree/Diploma _______________________________

4. Duration of Degree/Diploma _______________________________

5. Name of the Institution in which student _______________________________

Is studying & state in which situated _______________________________

6. Is the Institution recognized by the _______________________________

Govt. or affiliated to a University, pl. state _______________________________

c. School Record of the Child S.No. Name of the Qualified

Examinations on basis of which

admission taken

Year in

which

passes

Total Marks

obtained

Division in which

passes/Grade obtained

Percentage of

Marks

obtained

1 Matriculation/High School

2 Senior Secondary/10+2

3

4

Dated: ________ Signature of the Employee ____________________

Signature & Stamp of Sr. Subordinate

NORTH CENTRAL RAILWAY

DECLARATION

I hereby declare that my son/daughter for whom application is being submitted is not in

receipt of any stipend or assistance from any other source. I also give an undertaking that in case any

stipend or assistance is granted to him/her, subsequent to the grant of scholarship now applied for,

this will be immediately brought to the notice of the Chairman, Divl. Sub. Committee, Staff Benefit

Fund, Allahabad (Sr.DPO/ALD). I also declare that if my son/daughter fails to pass any examination

held in the institution where is studying, I will immediately supply this information to the Chairman,

Divl. Sub. Committee, Staff Benefit Fund, Allahabad (Sr.DPO/ALD).

Signature of the Employee ____________________

Name of the Employee ____________________

Desig. /Stat ____________________

CERTIFICATE FROM IMMEDIATE OFFICER

I have gone through the application and certify that the information given by the employee is

correct.

Seal & Signature of the Immediate Subordinate/Officer

Certificates to be attached

1. Attested copy of the Matriculation/Secondary/10+2 certificate & mark sheet of the student.

2. A certificate on Prescribed Performa from the Head of the Institution where the student is

studying.

NORTH CENTRAL RAILWAY

CERTIFICATE FROM THE PRINCIPAL OF HEAD OF INSTITUTION IN WHICH THE STUDENT IS STUDYING (FORM-A)

Certified that_____________________________________________________

son/daughter of Shri/Smt. ______________________________________ working as

__________________ in Allahabad Division of North Central Railway is a student of this

institution and is at present studying in the I/II/III/IV/V year of

____________________________ (Course). The duration of the course is ____________

years. The course session is from ______________ to _____________. The institution is

recognized by & affiliated to ______________________ and the examination is

conducted by the _____________________________. He/She is not in receipt of any

scholarship/assistance from any kind of source.

PARTICULARS OF THE FEES PAID BY THE STUDENTS ARE AS UNDER

1. Date of Joining the Institution ___________________________________

2. Date from which Fees paid ___________________________________

3. Yearly amount of tuition fee ___________________________________

It is also certified that a minimum educational qualification for admission to the

course, which the student is pursuing at Institution is _______________.

Dated: ____________ Seal & Signatures of the Head of Institution

CGA Application ANNEXURE-1

APPLICATION REQUESTING APPOINTMENT ON COMPASSIONATE GROUNDS

(To be filled in by the widow/widower of the deceased employee)

1) Particulars of the deceased employee

a) Name of the deceased employee …………………………………………………………………………… b) Designation, department& station …………………………………………………………………………… c) Community …………………………………………………………………………… d) Date of Birth …………………………………………………………………………… e) date of appointment ………………………………..…………………………………………. f) Date of Death ………………………………..…………………………………………. g) Age at the time of demise ………………………………..…………………………………………. h) Cause of demise ………………………………..…………………………………………. 2) Family Composition and details of occupation

Sl.No

Name Relationship

Age at the time of event

Date of Birth Occupation Remarks

Contd- 2

3) Details of claim for appointment on compassionate grounds

a)In case of widow apply for appointment for herself immediately after the event. Please furnish the following details

i) Name of the applicant --------------------------------------------------------

ii) Date of application --------------------------------------------------------

( Application to be attached)

iii) Date of birth --------------------------------------------------------

iv) Educational Qualification --------------------------------------------------------

( Proof attached)

v) If illiterate original sworn affidavit

Should be produced --------------------------------------------------------

b) If the request is for the ward, following details to be furnished

i) Applicant’s Name --------------------------------------------------------

ii) Date of Birth --------------------------------------------------------

iii)Educational qualification / Technical

Qualification.(proof to be attached)-------------------------------------------------------

iv) Is willingness taken from elder

sons /elder daughters obtained and

attached :

v) Is bread winner certificate is attached :

C) If the request is for eldest ward who is minor, the following details to be furnished.

i) Applicants name -------------------------------------------------

ii) Date of first application for appointment -------------------------------------------------

his/her favour

iii) Date of Birth --------------------------------------------------

iv) Date of attaining majority --------------------------------------------------

These should be

attested in case the

appointment is sought

for ward other than

first son/daughter

v) Date of application submitted after --------------------------------------------------

Attaining majority of the first child

Signature of the applicant Signature of the widow

Divisional Office Personnel Branch Date of receipt Sr.Divisional Personnel Officer Sri/Smt…………………………………………………. …………………………………………………………. …………………………………………………………. …………………………………………………………. …………………………………………………………

ANNEXURE-A

DECLARATION

(To be furnished by the candidate only)

I,……………………………………………………………………...son of/daughter of /wife of late

Shri…………………………………………………………….hereby declare and state that I have applied vide

my application dated………………………….for appointment on compassionate ground in Group-

‘C’/Group’ D’ service and that I confirm that no other dependent in the family of the said

deceased employee has so far been appointed in any capacity in the Railways on

compassionate grounds. This being the first application, I request that I may kindly be

appointed on compassionate grounds.

I also declare that the School/college Certificates produced by me are genuine and

have been obtained from the School/College where I have studied. I also declare that I an un

employed and not working anywhere.

I am aware that in case of my declaration being found false at any time in future, I am

liable to be terminated forthwith without assigning any reason from the Railway service.

Signature: ___________________

Name: ___________________

Date: ___________________

Witness: Signature : _________________________

Name : _________________________

Desgn & Stn : _________________________

Signature : _________________________

Name : _________________________

Desgn&Stn : _________________________

ANNEXURE-B

CERTIFICATE

(Certificate from Gazetted Officer)

I, …………………………………………………………… do hereby declare and certify that I know the

family of late Shri/Smt………………………………… intimately for the past………………………………years.

I also certify that Shri/Smt………………………………….. is the wife /husband/son/daughter of late

Shri/Smt………………………………whose photograph affixed duly attested hereunder. To my

knowledge none in the family has been appointed in Railways on compassionate grounds so

far.

The family of (late) Shri/Smt …………………………………………………is presently

residing at…………………………………………………………………….

.

Photograph of the

candidate (To be

attested by a

Gazetted Officer)

ANNEXURE-C

CERTIFICATE

(TO BE FURNISHED BY THE CANDIDATE OTHER THAN THE WIDOW) I understand that I am being considered for appointment in Railways on compassionate grounds on account of the death of my……………………………………………..(relationship) late Shri/Smt…………………………………………………………(deceased employee).

I ………………………………………………………..(Name of the candidate) …………………………………(relationship) of late Shri/Smt………………………. (Deceased employee) do hereby promise that I will look after the dependents of the deceased employee and shall act as a bred-winner of the family. I am also aware that my service shall be liable to be terminated if I fail to do so.

Place : Signature of the candidate.

Date :

Witness

Name : ………………………………………..

Address : ………………………………………..

………………………………………..

………………………………………...

Signature :

Name : ………………………………………..

Address : ………………………………………..

………………………………………..

………………………………………...

ANNEXURE-D

I Particulars of all dependent family members of the Railway servant(if some are employed, their income and whether they are living together or separately)

Sl.No Name(s) Relationship with the Government servant

Age Address Employed or not (if employed particulars of employment and emoluments)

(1) (2) (3) (4) (5) (6)

1

2

3

4

5

II

DECLARATION/UNDERTAKING

1) I hereby declare that the facts given by me above are, to the best of my knowledge, correct. If any of the facts herein mentioned are found to be incorrect or false at a future date, my services may be terminated.

2) I hereby also declare that I shall maintain properly the other family members who

have been dependent (details given above) on Railway servant mentioned against I (a) of part-A of this form and in case it is proved at any time that the said family members are being neglected or not being properly maintained by me, further during the period of their dependency my appointment may be terminated.

Date:

Signature of the candidate: ________________

Name: ____________________________

Address: ____________________________

I have verified that the facts mentioned above by the candidate are correct

Date: Signature of the Welfare officer:

Name: ____________________________

Stn.: ____________________________

Particulars pertaining to the ward/widow/dependent applied for appointment on compassionate grounds

1) Name ---------------------------------------------------

2)Deceased employee’s Name,

Designation& Station ---------------------------------------------------

3) Date of death ---------------------------------------------------

4) Relationship to the deceased ---------------------------------------------------

5) Age & date of Birth ---------------------------------------------------

7) Whether Group of post applied

for is Gr.’C’ or Gr.’D’ ---------------------------------------------------

8) Community & Cast ---------------------------------------------------

9) Present postal address ---------------------------------------------------

10) signature of the applicant ---------------------------------------------------

Witness

Name Design/Station Signature

1 --------------------------------------------------------------------------------------------

2 --------------------------------------------------------------------------------------------

3 --------------------------------------------------------------------------------------------

IDENTIFICATION CERTIFICATE

This is to certify that Shri/Smt/Km. …………………………………………….

Son/Daughter/Wife of (late)Shri/Smt……………………………………..a resident of

……………………………………………………………………………………………………………… is

known to me. She/He has applied for appointment on compassionate Grounds

in Gr.’C’/’D’ post in NC Railway Allahabad Division. The photo affixed by the

party duly attested by me. His specimen signature was obtained before me.

Specimen Signature of the applicant:

Attested ( By Gazetted Officer )

Latest passport size

photo is to be

affixed and attested

Application for sanction of Child Care Leave

Rly. Bd.’s Letter No. E(P&AII 2006, CFC/LE S dated 23/10

(To be submitted before 15 days of availing Child Care Leave)

1. Name Smt. ________________________________________

2. Designation ________________________________________

3. Pay Band & Pay ________________________________________

4. Working under ________________________________________

5. Child Care Leave Required ________________________________________

6. Earlier Child Care Leave Availed __________________________________

7. (Including leave not due After 740 days for Child Care leave)

8. Name of Minot children for whom favored

Child care leave required ________________________________________

9. Proof of date of birth ______________________________________________

In favor of minor children availing child care leave.

10. Certified that I am having _______Nos. of children and _______child (eldest) of mine

against whom Child care leave is requested.

Note:-

1. Children should be below 18 years up to the date of availing child care leave. 2. The child care leaves be admissible for two eldest surviving children only. 3. Child care leave can be sanctioned by an authority competent to grant 4. Child care leave is admissible for 730 day only during their ensure notice for taking

care of up to two children in more than one spell. 5. Employees cannot proceed on CCL without prior proposal approval of the leave by the

leave sanctioning authority. 6. Consequently Saturday, Sunday, Gazetted holidays etc. during the period of leave

would also count for CCL, as the case of earned leave.

Dated;_______________________ ( Signature of the employee)

B.

Forwarded to___________________(Branch officer/competent authority) for sanction of

child care leave in favour of Smt._________________________ from ________________to

_________________total _______Nos. of days. Certified that she had balance NIL earned

leave earlier she had availed _______No. of CCL and No.____of days balance in account of

Child Care leave and shall be debited in the account of Child Care leave after receipt of

sanction by APO/ADEN_____________ before proceeding on child care leave.

Signature of Sr. subordinate in charge,

(with stamp)

C.

Sanctioned child care leave in favour of ________________________from___________

to____________ total_______Nos. of days and return to concerned Sr. subordinate for debiting in the child care leave account.

Signature of competent authority.

NORTH CENTRAL RAILWAYAY Application for Encashment of Leave on average Pay (LAP) while in service under Rule 540-A

of Indian Railway Establishment Code Vol. I [Authority: Ministry of Railway’s letter No. F(E)III/2008/LE-1/1 dt: 29-10-2008]

***

1 Name (In Block letters)

2 PF No.

3 Bill Unit No.

4 Designation & Station

5 Department

6 Date of Birth

7 Date of Appointment

8 Date of Superannuation

9 Pay

10 No.of LAP available at credit

11 No.of days LAP propose to encash

12 No.of days of LAP so far encashed

13 Date of last encashment of LAP

14 Details of Privilege Pass availed (At the time of encashment period)

15 No.of LAP availed/proposed to avail (At the time of encashment period)

I, …………………………………. do hereby declare that the particulars furnished above are true. Date: Place: Signature of the employee

Forwarded for necessary action please. Signature of the Supervisory Official

Electronic Fund Transfer Mandate Form

A Name

B Designation

C Name of the Bank

D Address of the Bank

E Account No.

F Type of Account Current/Saving

G MICR Code

H RTGS/IFC Code of the Bank

I, hereby declare that the particulars given above are correct and complete. Date:

Signature and Stamp

Address………………………………….

……………………………………………..

Phone No…………….…………………. Counter Signature of the Bank Authority With Bank Seal

APPLICATION FORM FOR RESERVATION OF ACCOMMODATION IN THE HOLIDAY HOME AT ______________________________.

1. Name of employee ________________________________________________

2. Designation _________________________ (A) Class III/IV ____________

(B) Gr. RS. __________________ (C) Rate of Pay __________________

3. Department _______________________

(a) Place of work_________________ (b) Division_______________

(c) Railway_______________(d) Rly. Telephone No._____________

4. Date of Appointment ______________________________________

5. Whether coming on leave Yes/No.____________________________

6. Reservation required from _______________to_________________

7. State, if alternative dates are acceptable in case of accommodation is

not available for the dates applied for

Yes/No _______________from ___________to_______________

8. State, if accommodation of the above, Holiday Homes was availed in

previous year, if yes, give year.______________________

9. Particulars of family member to accompany the applicant.

S.No. Name (Sh/Smt) Relation Age

I, request that one unit in the holiday home at ____________may be allowed for the

bonafied use of self and family as particulars mentioned against item No.9 of the above

proforma rules and conditions regarding occupation of the holiday read by me explained to

me and I agree to abide the same.

I also certify that either myself or any member of my family who will be accompanying

me to the holiday home is not suffering from any infectious deceases and the family

members.

I, agree to pay to the authority concerned prescribed charges in advance and

hereby authorized my bill complying office to recover from the salary the cost of any

breaking of furniture’s equipment and lasses or any articles t the room that it be allotted for

my use.

Forwarded for necessary action.

Signature of the Applicant.

(Signature & Designation of the immediate /Sr. subordinate incharge officer)

Form for giving prior intimation or seeking previous sanction under Rule 18(2) of the CCS(Conduct) Rules 1964 transaction in respect of Immoveable Property. ******* 1 Name & Designation ____________________________________

2 Scale of pay & present pay ____________________________________

3 Purpose of application sanction for ____________________________________

For transaction/prior intimation of ____________________________________

Transaction.

4 Whether Property is being acquired ____________________________________

or disposed off.

5 Probable date of acquisition/ ____________________________________

disposal of property.

6 Mode of acquisition/disposal ____________________________________

7 a) Full details about location Viz. ____________________________________

Municipal No.Street/Village/Taluk

Distt.& State in which situated. ____________________________________

b) Description of the property in the ____________________________________

case of cultivable land, dry or ____________________________________

irrigated land.

c) Whether free hold or lease hold ____________________________________

d) Whether the applicant’s interest ____________________________________

in the property is in full or part

(In case of partial interest, the ____________________________________

extent of such interests must

be indicated).

e) In case the transaction is not ____________________________________

exclusively in the name of the

Govt.servant particulars of ____________________________________

ownership & share of each member

8. Sale/Purchase price of the property ____________________________________

(Market value in the case of gifts).

9. In case of acquisition source or ____________________________________

Sources form which financed/proposed to be financed.

a) Personal savings. ____________________________________

b) Other sources giving details. ____________________________________

10 In the case of disposal of property was requisite __________________

sanction/intimation obtained/given for its acquisition __________________

(A copy of the sanction/acknowledgement should be __________________

attached).

11. a) Name & address of the party with whom __________________

transaction is proposed to be made.

b) Is the party related to the applicant? __________________

If so, state the relationship.

c) How was the transaction arranged? __________________

(Whether through any statutory body or a

private agency through advertisement or __________________

through friends and relatives. Full

particulars to be given).

12. In case of acquisition by gift, whether sanction __________________

is also required under rule 13 of the CCS(Conduct)

Rules 1964.

13 Any other relevant fact which the applicant may like __________________

to mention.

DECLARATION

I __________________________ hereby declares that the particulars given above are

true & request that I may be given permission to acquire/dispose of property as described

above from/to the party whose name is mentioned in item No.11 above.

I __________________________ hereby intimae the proposed acquisition, disposal of

property by me as derailed above, I declare that the particulars given above are true.

Station------------- Signature-------------------

Date-------------- Designation----------------

Note:- 1. In the above form different portions may be used according to requirement.

2. Where previous sanction is asked for, the application should be submitted at

least 30 days before proposed date of the transaction.

Form for giving prior intimation or seeking previous sanction under Rule 18(3) of the CCS(Conduct) Rules 1961 transaction in respect of Moveable Property.

******* 1 Name & Designation --------------------------------------- 2 Scale of pay & present pay --------------------------------------- 3 Purpose of application sanction for --------------------------------------- for transaction/prior intimation of transaction. 4 Whether Property is being acquired --------------------------------------- or disposed off. 5 a)Probable date of acquisition/ -------------------------------------- disposal of property. b)If the property is already acquired/ ------------------------------------- disposed off actual date of transaction. 6 a)Declaration of the property (e.g) --------------------------------------- Car/Scooter/Motor Cycle/ Refrigerator/Radio/Radiogram/ Jewellery/Loan/Insurance Polices etc. b)Make Model (an also registration --------------------------------------- No.in case of vehicles) where necessary. 7. Mode of acquisition disposal ------------------------------------ (purpose/sale/gift mortgage leave or otherwise) 8. Sale/purchase price of the property ------------------------------------- (Market value in the case of)

9 In case of requisition source of -------------------------------------- or sources from which financed/proposed to be financed.

a) Personal savings --------------------------------------- b) Other sources. ---------------------------------------

10 In the case of disposal of property was requisite ------------------------- sanction/intimation obtained/given for its acquisition (A copy of the sanction/acknowledgement should be attached).

-2- 11. a) Name & address of the party with whom ------------------------- transaction is proposed to be made. b) Is the party related to the applicant? ------------------------ If so, state the relationship. c) Did the applicant have any dealings with the ------------------------ party in his official capacity at any time, or in the capacity at any time or is the applicant likely to have any dealing with him in the near future. d) Nature of official dealings with the party. ----------------------- e) How was the transaction arranged? ----------------------- (Whether through any statutory body or a private agency through advertisement or ----------------------- through friends and relatives. Full particulars to be given). 12. In case of acquisition by gift, whether sanction ----------------------- is also required under rule 18 of the CCS(Conduct) Rules 1961. 13 Any other relevant fact which the applicant may like ------------------ to mention. DECLARATION I-------------------------------------------hereby declares that the particulars given above are true & request that I may be given permission to acquire/dispose of property as described above from/to the party whose name is mentioned in item No.11 above.

I-----------------------------------------hereby intimae the proposed acquisition, disposal of property by me as derailed above, I declare that the particulars given above are true.

Station------------- Signature-------------------

NORTH CENTRAL RAILWAY

MEDICAL REIMBURSEMENT

‘A’ TO LETTER No. 494-E/C/III/EiV dated 24/3/99 – 31/3/99.

1. Name of Employees/Ex/employee.

2. Whether serving or retired.

3. Designation.

4. Office/Unit of Posting.

5. Pay & scale of Pay of employee pay last drawn in case of ex-employee.

6. Name of Patient.

7. Relationship with family employee for whom Re-imbursement is claimed.

8. Age of patient.

9. Medical/ I/Card No.

10. Whether referred or non-referred.

11. If referred by whom?

12. Name of the Institution where treatment is taken.

13. Date of Admission.

14. Date of Discharge.

15. Date of submission of claim.

16. Reasons for delayed, submission of claim, if delayed for more than 6 months.

17. Total period of stay as indoor Indoor patient.

18. Reasons for long stay (if stayed for More than 18 hrs.)

19. Type of medical emergency. 20. Was there no Railway/Govt. facility available dealer? 21. Distance of the nearest Govt. Hospital

& whether facilities available there.

22. Distance of the nearest Railway Hospital and Whether facilities available there. If not, how far

Is the Railway Hospital with the facilities available.

23. Distance of the Private Hospital from

Residence/place of illness, where Facilities availed.

24. When the Railway Medical Officer was Informed about such admission.

25. Does the patient take any treatment Before or after for the present sickness (if this existed before) and if yes, when?

26. Total amount claimed (with break-up of charges (detailed instructions at (f) of feature below).

27. Total number of enclosures. Counter sign. of controlling Signature of employee Officer/Unfit Incharge of employee/spouse (In case of serving employee only) Declaration to be signed by the person claiming medical re-imbursement. I, hereby declared that the statements in the application arfe grue to the best of my knowledge and belief and i) that the person for whom medical expenses were incurred is wholly dependent upon me. ii) the medical expenses were incurred for self, (strike out which is not applicable from (i) & (ii) above.

Station. Signature of Railway Servant. Dated. Design. & office to which attested. Foot-Note.

1. Item No.18,19,20,21,22,23,24 and 25 are applicable only for non-referred cases. 2. Following documents should be attached with this proforma. a) Employees/Retired employees application giving circumstances under which he/she took

treatment. b) Photocopy of Medical /RELHS I.D.Card duly attested by Gazetted Officer. c) Essentiality certificate issued by the treating Doctor of hospital countersigned by Medical

Supdt. Of the treating Hospital. d) Discharge certificate /slip in original. e) Bills /Vouchers (in original) duly counter signed by treating Officer/Authorized M.D). f) Detailed item wise break-up of all bills (this means all bills/vouchers submitted at (a)

above be reproduced in LEGIBLE MANNER for e.g.:

g)

Bill No. Name of Chemist/Shop Date

Description of Item Quantity Price

i)

ii)

iii)

iv)

Total

h) In case of referred cases, attach original referred slip.

Instructions for submission. In referred cases, the application duly countersigned by controlling officer/subordinate incharge should be submitted to the Medical Establishment from where he/she was referred. In un-referred cases, the application duly countersigned by controlling officer/subordinate incharge should be submitted to the ‘P’ Branch concerned to the call set up for the purpose of handling Medical re-imbursement case. FOR OFFICIAL USE ONLY:

I) In case of all cases being sent to Board. II) In case of AGM’s sanction for un-referred / Non-Govt. un-recognized cases.

Vibrating views of G.M. Vibrating views of FA & CAO. Signature of C.A.O.

PASS PORT APPLICATION FOR ISSUE OF ‘NO OBJECTION CERTIFICATE’FOR OBTAINING PASSPORT.

To,

________________________ ________________________

_______________________ (Through Proper Channel) Sub: Request for issue of “No objection Certificate” for obtaining a Passport. I wish to obtain a Passport for visiting ___________________, I request that I may kindly be granted “No objection Certificate” to enable me to produce it before the appropriate Passport issuing authority. The detail of my bio-data and other particulars are given below:-

1. NAME

2. DESIGNATION.

3. FATHER’s NAME

4. DATE OF BIRTH

5. DATE OF APPOINTMENT

6. GRADE & RATE OF PAY

7. DIVISIION/BRANCH IN WHICH WORKING

8. STATION OF POSTING

9. PRESENT RESIDENTIAL ADDRESS.

10. PLACE OF RESIDENCE DURING THE LAST 5 YEARS.

11. PRESENT ADDRESS

12. COUNTRIES FOR WHICH PASSPORT IS REQUIRED.

13. REASONS FOR OBTAINING PASSPORT.

I declare that :- 1. I will be abide by the provision of Indian Passport Act, Indian Custom Act and any

other Act of the Government of India.

2. I will not request for release of foreign exchange from Railways and will make his own arrangement for foreign exchange required for the trip.

3. I understood that issue of passport will be subject to the clearance from Civil

Authorities and the Income Tax Department.

4. I will not pursue any study or training while aboard without prior permission of the Administration.

5. I will not indulge in any activity which might be prejudicial to the interests of India or

any other foreign country and that his / her additives during this/her stay abroad will not affect the friendly relations between Indian and any other country/countries.

6. I will get the approval and sanction of leave from the appropriate competent authority

every time before proceeding abroad.

7. I will abide by the general conditions as laid down by the Government of India from time to time.

8. I have read the provisions under section 6 (2) of Passport Act 1967and certify that

these are not attracted in my case. There is nothing under the provision of said act which can debar for obtaining a passport.

Yours faithfully, Station. Signature of Applicant. Dated. with Name below the Signatures. Forwarded to: DRM/ADRM DRM Office for necessary action. There is nothing under section 6 (2) of Passport Act 1967 which can debar me for obtaining a passport. Countersigned. Station. Signature of the Sr.Sub. Incharge Branch Officer Name Designation Designation Dated. Date.

NORTH CENTRAL RAILWAY D.R.M.’s Office,

ALLAHABAD. No. _________________________ ________________________ ________________________ (Through____________________) Sub: Issue of “No objection Certificate” for obtaining a Passport. Ref: Your Application dated____________ received under letter No.___________________________dated_____________. Certified that Shri/Km.________________________________________ son/daughter/wife of Sh.___________________________is a temporary/permanent employee of this office (Address)________________________________________________________ ________________________________from_________________(date) and is at presenting holding the post of ___________________Shri/Smt./Km. _____________________________________ and his/her identity is certified. This Ministry/Department/Organization has “No objection” to his/her acquiring Indian Passport. He undersigned is duly/authorized to sign this identity certificate. I have read the provisions of section 6 (2) of Passport Act, 1967 and certify that these are n olt attracted in case of this applicant. I recommend issue of an Indian Passport t him/her. It is certified that the organization is a Central Government body. The identity Card Number of Sh./Smt./Km.(employee) _____________________________is ________________.

Applicant Photo to be attested

by the certifying Authority.

( ) Signature of the Authority Designation Of the Officer with Name & Office stamp.

Annexure

Shri/Smt.Km.________________________________ who has been granted this “No objection certificate” will bear in mind and comply the following general conditions:

i) He/she will abide by the provisions of Indian Passport Act, Indian Custom Act and any other Act of the Government of India.

ii) The “no objection certificate” issued is subject to the clearance from Civil Authorities and the Income Tax Department. iii) He/she will not seek any financial assistance from any foreign

country/institution/agency for his/her Itinerant.

iv) He/she will not pursue any study or training while abroad without prior permission of the Administration. v) He/she will not take up any employment or activity of profit while abroad. vi) He/she will not indulge in any activity which might be prejudiced to the interests of India or any lo the foreign country and that his/her additives during his/her stay abroad will not affect the friendly relations between Indian and any other country/countries. vii) He/she will get the approval and sanction of leave from the appropriate competent authority every time before proceeding abroad.

viii) The grant of “NOC” is subject t any other general conditions ad

laid down by the Government of India from time to time.

Annexure ‘C’

APPLICATION FOR ISSUE OF ‘NO OBJECTION CERTIFICATE’ ’FOR GOING ABROAD FOR SANCTION OF LEAVE TO BE AVAAILED OUTSIDE OF INDIA

To, ______________________________

Sir, Sub: Issue of “No objection Certificate” and sanction of leave to be availed of outside India. I am possession of passport No.________________ issued by _____________ which I have obtained on the basis of the “No objection Certificate” issued by you vide No. _________________________dated_______________. He passport is valid upto ____________________ I wish to proceed to _________for the purpose of I request that I may kindly be granted permission for the same. My application of leave from __________________to ___________________ is enclosed herewith. My service particulars and other details are given below:-

1. NAME ____________________________

2. FATHER’s NAME ____________________________

3. DESIGNATION ____________________________

4. DATE OF BIRTH ____________________________

5. DATE OF APPOINTMENT IN RAILWAY ____________________________

6. GRADE & RATE OF PAY ____________________________

7. DIVISION/BRANCH IN WHICH WORKING ____________________________

8. STATION OF POSTING ____________________________

9. PRESENT RESIDENTIAL ADDRESS. ____________________________

10. PERMANENT ADDRESS. ____________________________

11. PLACE OF RESIDENCE DURING THE LAST ____________________________

2 YEARS.

12. PLACE OF VISIT ABROAD WITH ____________________________

NAMES OF THE COUNTRIES ____________________________

13. DURATION OF THE VISIT. ____________________________

14. ADDRESS WHICH ABROAD. ____________________________

15. ESTIMATED EXPENDITURE ____________________________

16 SOURCE OF FUNDS. ____________________________

17 If the transaction for the source of funds requires the prior sanction of the competent authority as per the Railway service/Conduct rules, 1968 (Rules 18) sanction particulars of the same. I Declare that:- 1. I will not request for release of foreign exchange from Railway and will make my own arrangement for the foreign exchange required for the trip. 2. I will not over-stay abroad excerpt with the prior approval of the competent authority. 3. I will make my own arrangement to get my leave salary and other allowances while abroad. I understand that these amounts will be paid only in Indian Rupees. 4. I will not seek an financial / assistance from any foreign country/institution /agency for his/her itinerary. 5. I will not peruse any study for training while abroad without prior permission of the admn., 6. I will not take up any employment of activity of profit while abroad. 7. I will not indulge in any activity which may be pre-judicial to the interest of m my own country or any other foreign country and my activities dignity visit/stay abroad will not affect the friendly relations between my country and any other countries. 8. I will inform any change of address which may take place during my stay abroad to the Railway Administration. 9. I will not enter into any contract or marriage with a person other than Indian Nationality without prior permission of the Govt. 10. I will adhere to the provisions of Rule 18 of the Railway services (Conduct Rules 1956 in case I enter into any transaction for moveable property. 11. I clearly understand that I am liable for action under D&AR Rules in case violate any of the above provisions at any conduct of unbecoming of a Railway Servant I am abroad.

Yours faithfully, Station. Signature of Applicant. Dated. with Name below the Signatures.

NORTH CENTRAL RAILWAY

D.R.M.’s Office, Allahabad

No. Dated: _________________________ ________________________ ________________________ Sub: Issue of “No objection Certificate” and sanction of leave to be availed of outside India. Ref: Your application dated________________________. With reference to your application referred above, DRM/DLI has grated permission to you

for going to _____________________and has also sanctioned leave from _________________to

________________ and permission from ________________.

The above permission is subject to the conditions mentioned overleaf.

Divl. Personnel Officer,

Allahabad Copy to:- 1. 2. Important conditions annexed to be followed by the person given permission for going abroad.

1. He will not request for release of foreign exchange from Railway and will make my own arrangement for the foreign exchange required for the trip. 2. He will not over-stay abroad except with the prior approval of the competent authority. 3. He will make my own arrangement to get his leave salary and other allowances while

abroad. It should be clearly understand that these amounts will be paid only in Indian Rupees.

4. He will not seek an financial / assistance from any foreign country/ institution /agency for his Itinerant . 5. He will not peruse any study or training while abroad without prior

permission of the admn.,

6. He will not indulge in any activity which may be pre-judicial to the interest of India or any other foreign country and his activity during his stay abroad will not affect the friendly relations between India and any

other countries. 7. He will not take up any employment or activity of profit while abroad 8. He will inform of any change of address which may take place during his stay abroad to the Railway Administration. 9. He will not enter into any contract or marriage with a person other than Indian

Nationality without prior permission of the Govt. 10. He will adhere to the provisions of Rule 18 of the Railway services (Conduct Rules 1956 in case I enter into any transaction for moveable property. 11. It should be clearly understand that he would be liable for action under D&AR Rules

in case violation of any of the above provisions at any conduct of unbecoming of a Railway Servant while abroad.

Yours faithfully, Station. Signature of Applicant. Dated. with Name below the Signatures.

Application for VRS From …………………….. ------------------- ------------------- To The Senior Divisional Personnel Officer North Central Railway ALD Division Sir,

Sub: Request for Voluntary retirement on medical grounds and appointment to ward on

Compassionate grounds in Group ‘D’ category ***

I was medically unfitted in class ….. and declared fit in class…… vide MMS/ALD medical certificate No …………………………………..dated……… . Now, I am continuing on Supernumery Post with effect from ………… I am not able to continue in service due to my physical ailment. Hence, I opt for voluntary retirement on Medical grounds and I request that my son/daughter………………………………………….may please be considered for appointment on compassionate grounds in terms of Bds letter No E(NG)II/95/RC-1/94 dt 14.06.2006. I am aware that in case my request for Voluntary retirement is accepted, my son/daughter is entitled for appointment in Group D service only and I will not claim for Group ‘C’ appointment at a later date. Thanking you,

Yours faithfully, Date:

To

Reg: Grant of leave not due. Sir, As you are aware that I have on prolonged sickness since ____________ I have availed all leave on full and half average pay which was at my credit. I am in great distress, because jI am on leave without pay. I have come to know that no assistance from staff benefit fund is due to me. I, therefore, request you to kindly grant me “Leave Not Due” for_________days which is the leave that can be sanctioned in advance and adjusted after resumption. I am covered by C.P.C. lave rules. I clearly understand that I am liable to refund all the money received on account of leave not due in case of leave service on my own accord during the currency “LEAVE NOT DUE” and I will be considered finally retired from the date of commencement of LEAVE NOT DUE.

Yours faithfully.

Signature with name & Designation. Station of working.

CERTIFICATE FROM MEDICAL AUTHORITY. Certified that I have examined Sh.________________________employed under______________as

___________________who is under treatment since _____________and I am of the opinion that there is every reasonable chance of his recovery and earning leave on his resumption. I, therefore, recommend “Leave not due” for__________days on his case or I, therefore, do not recommend “Leave not due” in his case and instead I recommend grant of assistance from staff benefit fund as per extent rules.

Dated: Signarure.

FORM OF AGREEMENT TO BE EXECUTED AT THE TIME OF DRAWING AN ADVANCE FOR THE PURCHASE OF A MOTOR VEHICLE.

An agreement made on _________________ day of ________________ two thousand _______________ hundred _______________ between _________________ of __________________________( hereinafter called the Borrower which expression shall include his heirs, administrators, executors and legal representatives) of the One Part AND the President of India (Hereinafter called the President, which expression shall include his successors and assignees) of the other part. WHEREAS, the Borrower has under the provisions of the Indian Railway General Code (hereinafter referred to as the Paid code which expression shall include any amendments thereof for the time being in force) applied to the President for a loan of Rs._________________________________________ for the purchase of a motor vehicle and WHEREAS the President has agreed to lend the said amount to the Borrower on the terms and conditions hereinafter contained. NOW IT IS HEREBY AGREED between the parties hereto that in consideration of the sum of Rs._______________________ paid by the President to the Bowwower ( the receipt of which the Borrower hereby acknowledges) the Borrower hereby agrees with the President (1) to pay the President the said amount with interest calculated according to the said Code by monthly deductions from his salary as provided in the said Code and hereby authorizes the President to make such deductions and (2) within one month from the date of these presents to expand the full amount of the said loan in purchase of a Motor vehicle or if the actual price paid is less than the loan to repay the difference to the President forthwith and (3) to execute the document hypothecation the said motor vehicle to the President as security for the amount lent to the Borrower is aforesaid and interest in the form provided by the said Code and IT IS HEREBY LASTLY AGREED AND DECLARED THAT IF THE MOTOR VEHICLE has not been purchased and hypothecated as aforesaid within one month from the date of these presents or if the Borrower within that period becomes involvement or quit the service of the Government or dies, the whole amount of the loan and interest accrued thereon shall immediately become due and payable.

IN WITNESS WHEREOF THE BORROWER and for and on behalf of the President have hereunto set their hands the day and year first become written.

* Signed by the said in presence of

1. 2. Signature of witnesses Station office Date (Signature and designation of Officer) Station Office Date

Signature of authority for and on behalf of President for India

APPLICATION FOR PURCJHASE OF MOTOR CAR/CYCLE/SCOOTER ADVANCE.

1. Name of the Applicant 2. Design. / Branch. 3. Pay

a)Substantive Pay

b)Officiating pay or pay drawn in a type post.

4. Anticipated period of motor car/clcle. 5. Amount of advance applied/required. 6. D.O.B.__________________D.O.A________________. 7. Date of superannuation or retirement or date of expiry of contract in case of a contract officer. 8. Number of installments in which the advance is desired to be paid. 9. whether advance for the purchase of any conveyance obtained previously and if so.

10. a) Date of drawl of advance.

b) The amount of advane and or interest thereon till outstanding if any.

11. Whether the invention is to purchase.

b) New or old Motor Car/Cycle/Scooter. c) If the intention is to purchase Motor Car/Cycle/Scooter through a person other than a regular or

reputed dealer or agent. Whether provious sanction of the competent authority has been obtained as desired under rule 15 (2) of the Central Services (Conduct)Rule 1956.

1. Whether the officer is on leave or is about to proceed on leave. a) The date of commencement of leave. b) The date of expiry of leave.

2. Are any negotiations of preliminary enquiries being made so that delivery may be taken of the motor car/cycle /scooter within one month from the date of drawl of the advance.

3. a) Certified that the information given above is complete and true.

b) Certified that I have not taken delivery of the motor car/scooter/motor cycle on a/c on which I apply for the advance that I shall complete negotiation for purchase or pay finally and take possession or the motor/car/cycle/scooter before the expiry of one month from the expiry of one month from the date of drawl of the advance and I shall ensure it from the date of taking delivery of it.

Dated.__________________________ Signature of the Applicant.

G.22/B/(Rev.)-98

North Central Railway Allahabad

Application for L.A.P./L.H.A.P

1. Name of the Employee : ..................................................... 2. Staff/Ticket No. : .............…………........................ 3. Designation, Office and Station : ..........................…………........... 4. Leave applied for : ...... Days, From......……..... To........... 5. Details of any prefixing/suffixing of holidays: ……………………………………. 6. Reasons for applying for leave : ..................................................... 7. Address during absence : …………...................................... (Phone No. if any) : …………...................................... 8. Signature of the employee : Signature: …............................Date:……...

9. Recommendation of the supervisor : Signature:................………….... Date: with signature and designation Designation: …………………………

(For Office use only)

10. No. of days of leave at credit : ................................ as on ……………….. 11. Signature of certifying official with designation and office : Signature:…………………….. Date…….. Designation:…………………………..…… Office: ……………………………………….

12.Orders of the sanctioning authority : 13.Signature: ……......................... 14.Designation: ………………………………… 15. Date: …….

13. Balance leave at credit : …..................................... as on ……………. 14. Certified that the leave account of the employee has been updated as on : Signature: ……………………..Date: ……...

Designation: ………………………………….

TRAVELLING ALLOWANCE

Branch……………………Division/District…………………..Headquarters………………………………..

Journal of duties performed by Shri……………………….for which to allowance for ……..........is claimed

Designation………………….….Pay…………..…………..Date of appointment……………………..……..

Rule by which governed……………………………………………………………………………………….

Month

& date

No. of

train

Time

left

Time

arrive

d

Station

Kilometer

Day/

Night

Object of

journey

Rate

From To Rs. P.

1 2 3 4 5 6 7 8 9 10

(P.T.O.)

Continued from previous page-

1 2 3 4 5 6 7 8 9 10

It is certify that-

1 The T.A. claimed by me has not been claimed before & will not be claimed hereafter.

2 Conveyance charges claimed have actually been spent by me and according to local Municipal rates.

3 Cheapest mode of conveyance was utilized.

4 The journey performed by road for conveyance has been claimed was over 1.6 K.M.

……………………………..

Signature of Officer Claiming T.A.

I hereby certify that Shri……………………………….was absent on duty from his headquarters station during the

period charged for in the bill on Railway business and that the offer performed the journey by Rail/Sea/Air/Road and

was allowed/not allowed free.

…………………………..

Signature of Head of the Office

Controlling Officer

1 On T.A. Bills of transfer from one Railway to another a certificate whether or not a free Pass or

locomotion at Government express was allowed should be recorded.

ENQUIRY REPORT FOR N.O.C. TO VISIT ABROAD

1 Name :

2 Father’s name :

3 Designation and place of posting :

4 Date of Appointment and Rate of pay :

5 Station of posting during the last five year :

6 Permanent address

:

7 Present address

:

8 Date and place of birth :

9 Family History

i) Father

ii) Mother

iii) Wife / Husband

iv) Brothers

v) Sisters

vi) Sons

vii) Daughters

:

:

:

:

:

:

:

10 Purpose of visiting abroad and address :

11 Whether proceeding on leave or shall resign :

12 Financial sources for going abroad :

13 Any police Enquiry or DAR pending :

14 Trade union activities :

15 Remarks of Enquiry Officer :

To The _______________________ ________________________

Sub: - Request for voluntary retirement on medically ground being decategorised from the category_____________ GP__________.

R/Sir,

With due respect, It is stated that while I was working as_______________in GP__________. I have been medically decategorised from my original post _________and found suitable in medical classification_________________. But due to my family circumstances and my ill health I am not able to continue my services in Railway department in future. Presently I have more than__________years service left up to retirement on superannuation and I wish to appoint my son inlieu of myself on compassionate ground by taking voluntary retirement on medial ground.

It is therefore, requested that I may be voluntary retired from service and my son Sh._________________________may be considered for CG appointment.

Thanking You.

Your faithful