Application for issue of Post-Retirement Passes

INTEGRAL COACH FACTORY, CHENNAI – 600 038
Application for issue of Post-Retirement Passes

Applicant’s details: I.D. Card No.
Name (in BLOCK letters)
Residential Address

Phone No.
Emp. Number Designation
Last drawn Pay Rs. Scale of Pay
Class of Pass FIRST ‘A’ FIRST SECOND
Actual Railway service Dt. Appt. Rly. Quarters, if any, in occupation
Dt. Retirement
Total Service
Pass details:
Pass applied for Single Journey Return Journey
In favour of

[With / without companion
(If Companion is included,
date of birth may be
furnished for self and wife)] S.No. Relationship Date of birth Age
1.
2.
3.
4.
5.
Pass required (from-to Stations) From
To
Via Onward Journey 1 2 3 4
5 6 7
Return Journey 1 2 3 4
5 6 7
Break Journey 1 2 3 4
5 6 7 8
9 10 11 12
13 14 15 16
Date required
Declarations
1. Previous Pass No. dated is enclosed Yes / No
2. The Pass will be received by me /Shri on my behalf Yes / No
3. My attendant is employed on salary in my personal service on whole time basis. Yes / No
4. School Certificate in respect of my student son is enclosed Yes / No
5. I have vacated staff quarters after retirement Yes / No

Date: Signature of the Retired Employee
For office use only:
Pass No. Date of Issue Ledger Folio No. Issued by