Annexure-1

Roll No. (For official use only)

Control No: (For official use)

RAILWAY RECRUITMENT BOARD

APPLICATION FORM FOR CEN 05/2016 (For Group-C & D) PASTE (do NOT pin or staple)
here your recent colour
Please fill up the Application in CAPITAL LETTERS in own handwriting, passport size photograph
except signatures and at places indicated $ (where Capital letters should NOT be used) of size 3.5 cm X 3.5 cm
(The colour photograph
(All applications must be submitted in A4 Size 80GSM paper) (bond paper) should not be more than
3 months old)
Not to be attested
1. CATEGORY No.& POST Cat No. Name of Post:

2. CHOICE OF RAILWAY $
1st 2nd 3rd
(Whereever applicable)
Signature of the candidate in the above box
below the photograph
(NOT in capitals)

3. NAME OF CANDIDATE Shri/Smt./Kum.

4. a) FATHER’S NAME Shri

b) MOTHER’S NAME Smt.

5. a). COMMUNITY (Tick ) UR *SC *ST *OBC

*Certificate to be submitted in the format as prescribed in Annexure-3 for SC/ST & Annexure-4 for OBC.

b). If OBC please state whether belonging to Minority Community Yes No c). If minority, indicate community:

6. Tick ( ) Gender : Female Male

7. RELIGION : Hindu Muslim Christian Sikh Buddhist Jain Parsi Others

8. DATE OF BIRTH (DD/MM/YYYY)

9. AGE (as on 01-01-2013) Years Months Days

(Refer para 2 of Employment Notice)

10. Are you (i) Govt Employee Yes No (ii) Ex-Serviceman Yes No (iii) PWD Yes No if YES, VH OH HH

(iv) Is scribe required (refer para 10.06 of CEN.) Yes No

11. VISIBLE MARK OF IDENTIFICATION ON BODY
(To be filled compulsorily. If no such marks, write ‘NIL’ )
12. Qualification (Fill in only those qualifications prescribed for the posts applied for)

(A ) Academic Qualification University/Board Year of Passing Subjects Marks%

SSC/ X/ Matric

Higher Secondary/XII/Inter

(B) Technical Qualification University/Board Year of Passing Discipline Marks%

Diploma

Degree

Others

13. ADDRESS Name:

(FOR CORRESPONDENCE)

P.O: City: Dist:

State: PIN Code:

14. NEAREST RAILWAY STATION

(For issue of free Railway Pass
to SC/ST Candidates)
$
Left Hand Thumb Impression
of the Candidate in this box
Signature of the Candidate
(NOT in Capitals Letters)

Note : 1) Candidates must fill up their name, father’s name, mother’s name and date of birth as indicated in their Matriculation Certificate
2) Candidates should put their full signature at all the places in the same language (English or Hindi)
 INFORMATION SHEET Annexure-2
RAILWAY RECRUITMENT BOARD INFORMATION SHEET (For CEN 05/2012 Para-medical Categories)
(to be filled in CAPITAL LETTERS ONLY - Signatures should NOT be in Capital/Open letters)

1. NAME OF THE CANDIDATE

2. Marital Status : Married Un-Married 3. Nationality

4. MEDIUM OF EXAMINATION :
(Choose any one of the Regional languages of RRB concerned as given in para 15 of CEN, if other than English/Hindi & Urdu)

5. Permanent Address

P.O: City: Dist:

State: PIN Code:

6(a). Details of Postal Orders (IPO)/Demand Drafts(DD) enclosed
Name of Post Office / Bank Serial No. and Date Amount

6(b). Are you seeking fees exemption (Yes / No) if yes, ( ) tick appropriate box from the following

(i) As an Economically Backward class candidate (iii) As a Female Candidate

(Income certificate to be enclosed as per Annexure - 7)
(iv) As a SC/ST Candidate

(ii) As a Minority Candidate (v) As an Ex-serviceman

(Self declaration to be enclosed as per Annexure - 8) (vi) As a PWD
7. Judicially separated/ J&K Railway Course Completed
Do you seek age relaxation SC ST OBC Ex-SM PWD
divorced woman / Widow Resident Employee Act Apprentice
( ) TICK appropriate box

8. Present employment (To be filled by all Railway / Central /State / PSU employees)

Designation & Grade Date from Date to Name & address of Employer

9. Ex-Serviceman (Ex-SM)

Date of Enrolment Date of attestation Date of Discharge Length of Service

10. Whether you were debarred by any RRB in the past a) NO b) For Two years c) For LIfe
11. Documents attached in proof of : Indicate ( ) tick mark in the relevant boxes indicated below
Matric/SSLC Certificate Educational Qualification Certificate if any Discharge Certificate
IPO/DD (for DOB proof) Qualification proof (For Ex-Serviceman) (For Ex-Serviceman)

Community Certificate Self Declaration form OBC Self Declaration Disability Certificate NOC (for SRE/
(For SC/STas per candidates as per form Minority (for PWD as per Govt. /PSU employees)
Annexure - 3,OBC-as Annexure - 5 candidates as per Annexure-9
per Annexure - 4) Annexure - 8
Economically backward Certificate Declaration formVH candidates/candidates whose writing speed is
(Should be in the Letter Head of the issuing authority as per Annexure - 7) affected by cerebral palsy as per Annexure-10

12. Please copy the following declaration in the space provided below in your own running handwriting (NOT in capitals) :
(Not filling up the passage below/ filling in capital letters will disqualify the applicant)
“After carefully reading all the provisions of this CEN, I here by declare that I fullfill all the conditions of eligibility and undertake the
responsibility for the same. I further declare that all the statements made by me in this application are true, complete and correct to the best of
my knowledge and belief. In case of any of my statements are found to be false or incorrect or suppressing any facts at any stage of recruitment
or thereafter, the same would make me ineligible and my candidature/appointment shall be cancelled.

Left Hand Thumb Impression

of the Candidate in this box
$

Place :
Date : Signature of the Candidate
(NOT in capitals)
 Annexure-3
RAILWAY RECRUITMENT BOARD
FORM OF CASTE CERTIFICATE FOR SC/ST
A Candidate who claims to belong to one of the scheduled caste or scheduled tribe should submit in support of his/her claim a
self attested copy of a certificate in the form given below from the district magistrate or the sub-divisional officer or any other
officer as indicated below of the district in which his/her parents (or surviving parents) ordinarily reside and who has been
designed by the State Government concerned as competent to issue such a certificate. If both the parents are dead, the officer
signing the certificate should be of the district in which the candidate himself/herself reside otherwise than for the purpose of
his/her own education. Wherever, photograph is an integral par t of the certificate, the RRB would accept only self attested
photocopies of such certificates and not any other attested or true copy.
(The Form of the certificate to be produced by Scheduled Castes and
Scheduled Tribes candidates applying for appointment to posts under the Government of India)
This is to certify that Shri / Shrimathi / Kumari ................................................................................................................
son/daughter* of ........................................................... of Village / Town* .................................................................. in
District / Division* ......................................................................... of State / Union Territory*..........................................
belongs to the ..................................... Caste / Tribe* which is recognised 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) Order, 1951*
The Constitution (Scheduled Tribes) (Union Territories) Order, 1951*
(As amended by the Scheduled Castes and Scheduled Tribes Lists (Modification) Order, 1956, the Bombay Re-
organisation Act, 1960. the Punjab Re-organisation Act. 1966, the State of Himachal Pradesh Act, 1970 and
the North Eastern Area (Re- organisation) Act, 1971 and the Scheduled Castes and Scheduled Tribes Orders.
(Amendment) Act, 1976)
The Constitution (Jammu & Kashmir) Scheduled Castes order, 1956@
The Constitution (Andaman and Nicobar Islands) 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, 1962. The Constitution (Dadra and Nagar Haveli)
Scheduled Tribes Order, 1962.
The Constitution (Pondicherry) Scheduled Castes Orders, 1964 @
The Constitution (Scheduled Tribes) (Uttar Pradesh) Order, 1967 @
The Constitution (Goa, Daman and Diu) Scheduled Castes Order, 1968 @
The Constitution (Nagaland) Scheduled Tribes Order, 1970 @
The Constitution (Sikkim) Scheduled Castes Order, 1978 @
The Constitution (Sikkim) Scheduled Tribes Order, 1978 @
Shri/Shrimati/Kumari* ............................................................................................. and / or his / her* family, 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 applicable.
@Please quote the specific presidential order.
Note: The term “ordinarily reside(s) ** used here will have the same meaning as in Section 20 of the Representation of
the Peoples Act, 1950.
** Officers competent to issue Caste/Tribe certificates:
** District Magistrate / Additional District Magistrate / Collector / Deputy Commissioner / Additional Deputy Commissioner /
Deputy Collector / 1st Class Stipendiary Magistrate / City Magistrate / Sub-Divisional Magistrate / Taluk 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 Tahsilar /
Sub-Divisional Officer of the area where the candidate and / or his / her family normally reside(s).
Note: ST Candidates belonging to Tamilnadu State should submit caste certificate ONLY from the REVENUE DIVISIONAL
OFFICER
 Annexure-4
RAILWAY RECRUITMENT BOARD
OBC CERTIFICATE FORMAT
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 recognised as Backward Class under: (indicate the Sub Caste above)
1) Resolution No.12011/68/93-BCC@dated 10th September 1993, published in the Gazette of India -
Extraordinary-part 1. Section 1.No.186, dated 13th September 1993.
2) Resolution No.12011/9/94-BCC, dated 19th October 1994, published in the Gazette of India -
Extraordinary-part 1. Section 1.No.163, dated 20th October 1994.
3) Resolution No.12011/7/95-BCC, dated 24th May 1995, published in the Gazette of India -
Extraordinary-part 1. Section 1.No.88, dated 25th May 1995.
4) Resolution No.12011/44/96-BCC, dated 6th December 1996, published in the Gazette of India -
Extraordinary-part 1. Section 1.No.210, dated 11th December 1996.
5) Resolution No.12011/68/93-BCC, published in the Gazette of India -Extraordinary- No.129, dated the
8th July 1997.
6) Resolution No.12011/12/96-BCC, published in the Gazette of India -Extraordinary- No.164, dated the
1st September 1997.
7) Resolution No.12011/99/94-BCC, published in the Gazette of India -Extraordinary- No.236, dated the
11th December 1997.
8) Resolution No.12011/13/97-BCC, published in the Gazette of India -Extraordinary- No.239, dated the
3rd December 1997
9) Resolution No.12011/12/96-BCC, published in the Gazette of India -Extraordinary- No.166, dated the
3rd August 1998.
10) Resolution No.12011/68/93-BCC, published in the Gazette of India -Extraordinary- No.171, dated the
6th August 1998.
11) Resolution No.12011/68/98-BCC, published in the Gazette of India -Extraordinary- No.241, dated the
27th October 1999.
12) Resolution No.12011/88/98-BCC, published in the Gazette of India -Extraordinary- No.270, dated the
6th December 1999.
13) Resolution No.12011/36/99-BCC, published in the Gazette of India -Extraordinary- No.71, dated the 4th
April 2000.
Shri/Smt./Kum.* .......................................................................... and/or his/her family ordinary 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.36033/3/2004-Estt. (Res) dated
09.03.2004.
Place :
Date :
DISTRICT MAGISTRATE / DY. COMMISSIONER ETC.
*Strike out whichever is not applicable (With Seal of Office)

NB: (a) The term ‘ordinarily’ used here will have the same meaning as in section 20 of the Representation of
Peoples Act 1950. (b) The Authorities competent to issue caste certificate are indicated below : (I)District
Magistrate / Additional Magistrate / Collector / Deputy Commissioner / Additional Deputy Commissioner /
Deputy Collector / 1st Class Stipendiary Magistrate / Sub-Divisional Magistrate / Taluk Magistrate) (ii) Chief
Presidency Magistrate / Additional Chief Presidency Magistrate / Presidency Magistrate (iii) Revenue Officer
not below the rank of Tahsildar, and (iv) Sub-Divisional Officer of the area where the Candidate and or his
family resides.
 RAILWAY RECRUITMENT BOARD Annexure-5
Proforma for declaration to be submitted by Other Backward Class Candidates along with the application
while applying for the posts against Employment Notice No CEN 05/2012 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

recognised 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 08.09.1993. 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 08.03.1993 and its subsequent

through O.M. No. 36033/3/2004-Estt. (Res/) dated 09.03.2004”

Place: Signature of the Candidate

Date: Name of the candidate
 Annexure-7
FORMAT OF INCOME CERTIFICATE TO BE ISSUED ON LETTER HEAD OF ISSUING AUTHORITY
For Waiver of Examination Fees For RRB Examination
(Economically backward chasses only)
1. Name of Candidate : .......................................................................................................................
2. Father’s Name : .......................................................................................................................
3. Age : ...................................................................................................
4. Residential Address : .......................................................................................................................
5. Annual Family income : .......................................................................................................................
(in words & Figures)
6. Date of Issue : ...................................................................................................
7. Signature : ........................................Name.................................................
8. Stamp of Issuing authority : ...................................................................................................
Note: Economically Backward classes will mean the candidates whose family income less than Rs. 50,000 per
annum. The following authorities are authorised to issue income certificate for the purpose of identifying
economically backward classes
1. District Magistrate of any other Revenue Officer upto the level of Tehsildar.
2. Sitting member of Parliament of Lok Sabhas for persons of their own constituency
3. BPL Card or any other certificate issued by Central Government under a recognized poverty alleviation
programme or Izzat MST issued by Railways
4. Union Minister may also recommend to Chairman / RRBs for any person from anywhere in the country
5. Sitting Member of Parliament of Rajya Sabha for person of the district in which these Mps normally reside
 Annexure-8

RAILWAY RECRUITMENT BOARD

Proforma for declaration to be submitted by Minority candidates along with the application for the
post against Centalised Employment Notice No. 05/2012

DECLARATION
I...................................................................................................................... son/daughter of

Shri........................................................................................................................... Resident of

Village/Town/City...........................................................district..............................................

State .............................................................................................hereby declare that I belong

to ................................................................. (indicate your religion), which is notified as minority

community by the Central Govt.

Signature of the Candidate

Place:
Date: Name of the Candidate
 RAILWAY RECRUITMENT BOARD Annexure-9
FORM OF MEDICAL CERTIFICATE FOR PERSONS WITH DISABILITIES (PWD)
NAME & ADDRESS OF THE INSTITUTE / HOSPITAL Date:...........................
DISABILITY CERTIFICATE Paste here your recent color
Certificate No.................................................... photograph showing the disability
(The photograph should be
attested by the Chairperson
1. This is to certified that Smt./Shri/Kum* .......................................................................................
of the Medical Board)
son/daughter* of Shri ................................................................................................................
age ........................................................... sex Male/Female having identification marks as below
.............................................................................................................................................. is
suffering from permanent disability of following category:

A. Locomotor or cerebral palsy:

Signature of candidate in the above
(I) BL-Both legs affected but not arms. box below the photograph
(ii) BA-Both arms affected
(a) Impaired reach
(b) Weakness of grip
(iii) OL-One leg affected (right or left)
(a) Impaired reach
(b) Weakness of grip (c) Ataxic
(iv) OA-One arm affected (right or left)
(a) Impaired reach
(b) Weakness of grip (c) Ataxic
(v) BH-Stiff back and hips (cannot sit or stoop)
(vi) MW-Muscular weakness and limited physical endurance.

B. Blindness or Low Vision: (C) Hearing impairment :

(I)B-Blind (ii) PB-Partially Blind (I)D-Def (ii) PD-Partially Deaf
(Delete the category whichever is not applicable)

2. This condition is progressive/non-progressive/likely to improve/not likely to improve. Re-assessment of this case is not
recommended/ is recommended after a period of .......................... year ............................ months.
3. Percentage of disability in his / her case is .............................. percent.
4. Smt./Shri/Kum* ..................................................... meets the following physical requirement for discharge of his/her duties:
(I) F-can perform work by manipulating with fingers. Yes No
(ii) PP-can perform work by pulling and pushing. Yes No
(iii) L-can perform work by lifting Yes No
(iv) KC-can perform work by kneeling and crouching Yes No
(v) B-can perform work by bending Yes No
(vi) S-can perform work by sitting Yes No
(vii) ST-can perform work by standing Yes No
(viii) W-can perform work by walking Yes No
(ix) SE-can perform work by seeing Yes No
(x) H-can perform work by hearing/speaking. Yes No
(xi) RW-can perform work by reading and writing Yes No

(Signature of Doctor) (Signature of Doctor) (Signature of Doctor)

Name: Name: Name:

Registration No: Registration No: Registration No:

Member, Medical Board Member, Medical Board Member, Chairperson, Medical Board

*Please delete the words which are not applicable

Place: Counter signature of the Medical Superintendent/CMO/
Date: Head of Hospital (with seal)
Note: (i)According to the Persons with Disabilities (Equal Opportunities. Protection of Right and Full participation) Rules, 1996 notified on
31.12.1996 by the Central Government in exercise of the powers conferred by sub-Section (1)and (2) of Section 73 of the Persons with Disabilities
(Equal Opportunities. Protection of Rights and full Participation) Act. 1995 (1 of 1996), authorities to give disability Certificate will be a Medical Board
duly constituted by the Central or the State Government. The State Government may constitute a Medical Board consisting of at least three members
out of which at least one shall be a specialist in the particular field for assessing locomotor /hearing and speech (ii) The certificate would be valid for
a period of 5 years for those whose disability is temporary. for those who acquired permanent disability, the validity can be shown as permanent.
 RAILWAY RECRUITMENT BOARD Annexure-10
DECLARATION TO BE SUBMITTED BY VISUALLY HANDICAPPED CANDIDATES/
THOSE CANDIDATES WHOSE WRITING SPEED IS AFFECTED BY CEREBRAL PALSY
PARTICULARS OF SCRIBE PROPOSED TO BE ENGAGED BY THE CANDIDATE
1. Name of the Candidate .............................................................................. Control No: (for office use)
2. Date of Birth of the Candidate ....................................................................
Paste here recent color
3. Name of the Scribe .................................................................................... passport size
4. Father’s Name of the Scribe ....................................................................... photograph of the SCRIBE
of size 4cm x 5cm
5. Address of the Scribe : (The color photograph should not
(a) Permanent Address ............................................................................. be more than 3 months old)
..................................................................................................................
..................................................................................................................
(b) Present Address ................................................................................. Signature of SCRIBE in the above
.................................................................................................................. box below the photograph
..................................................................................................................
6. Educational Qualification of the Scribe
..................................................................................................................
..................................................................................................................
7. Relationship, if any, of the Scribe to the Candidate ......................................
8. DECLARATION
We hereby declare that the particulars furnished above are true and correct to the best of our knowledge and belief. We
have read/ been read out the instructions of the Railway Recruitment Board regarding conduct of the visually
challenged candidates/scribes at this examination and hereby undertake to abide by them. We also declare that:
(a) The academic qualification of the SCRIBE is below the qualification prescribed for the post applied for
*(b) The academic discipline of the SCRIBE is same as of the candidate since the application is for general posts/ The
academic discipline of the SCRIBE is different from that of the candidate as the application is for a specialist post. (Delete
the portion not applicable)
(c) The SCRIBE has not secured more than 60% marks in the qualification mentioned
*Strike out which is not applicable.

(Signature of the Candidate) (Signature of the Scribe)

Left Thumb impression of the Candidate Left Thumb impression of the Scribe
in the box given above in the box given above