Annexure A

Application for re-engagement in Mumbai Division, Central Railway

(Notification No BB/P/Loco/558/Re-engagement Dated 05.12.17)

To, Affix recent

Divisional Railway Manager (P) passport size Loco Section colour

Mumbai Division photograph with

Central Railway signature across

the Photo

I hereby apply for re-engagement as _____________ in___________Department on

Mumbai Division, Central Railway / Western Railway on daily remuneration basis, on terms and conditions mentioned in the said notification. My service particulars are as below.

1. Name: __________________________________________________________

2. Designation at the time of retirement : __________________________________

3. Division/ Unit / Department from where retired: ___________________________

4. Date of Birth : _____________________________________________________

5. Date of retirement : ________________________________________________

6. Retirement on Superannuation/VRS/LARGESS/ or any other retirement(specify) :

_____________________________

7. Address for correspondence: _________________________________________

_________________________________________

_________________________________________

8. Tel No : _________________________________,________________________

9. Last Pay Drawn – Pay Band Rs ____________________ GP_______________

10. P P O No ______________________________ Date______________________

11. Enclosure (copy of documents) : ______________________________________

a) Service Certificate

b) Pension Identity Card

c) Pension Payment Order

I declare that the information furnished above is true to the best of my Knowledge and I am liable for punitive action if found false / incorrect. I also declare that I have gone through the terms and conditions stipulated in the Notification and I shall abide by them. I have not retired under SRRS/ LARGESS

Signature of the Applicant Name:-

Date: - ___________________ Place:- ____________________