ANNEXURE 'A' TO SCHEDULE II
[See Rule 6(1)]
STANDARD RAILWAY PASS FORM
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Form No…. |
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Standard Railway Pass Form |
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With _____Kilogram luggage free for each adult and half that quantity for each child. |
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"The pass must be returned by the pass holder to the issuing office within a month of the date of expiry of the pass, with remarks used/cancelled. |
Name of Break journey availed of |
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FREE PASS……………….CLASS
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1. (a) Date of Arrival___ |
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Designation …………………………………….. |
(b) Date of Departure __ |
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Pass……………………………………………………. |
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From ……………………………………...To …………………………………….. |
2. (a) Date of Arrival___ |
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Via ………………………………………….and return via …………………………………….. |
(b) Date of Departure __ |
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Over[1] ……………………….. Railway. |
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Available upto |
Outward journey ……………………….. |
3. (a) Date of Arrival___ |
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Return journey ……………………….. |
(b) Date of Departure __ |
Signature/thumb impression of the holder. If the employee himself is not travelling The leading member of the family should sign or if illiterate put his/her thumb impression. |
Outward journey
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Return journey |
4. (a) Date of Arrival___ |
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To be signed at the
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(b) Date of Departure __ |
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*Outward journey commenced on ……………………….. 19…. |
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* Ret urn journey commenced on ……………………….. 19… |
5. (a) Date of Arrival___ |
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By any passenger train/mail train
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(b) Date of Departure __ |
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Why granted ……………………….. |
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………………………………………… Signature & designation of the Issuing Officer with seal |
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*The date must be inserted in INK BEFORE commencement of journey in either direction . Ticket Collectors and T.T.Es. must see that this is complied with. They should also recover a fine of Rs.25/- on I-A/I class and Rs.10/- on II Class passes for not entering the date of commencement of journey on passes and endorsing the fact of recovery of fine on passes. |
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References
1. Railway Board’s letter No. E(W) 2000 PS 5-1/11 dated 21.06.2004 (RBE No. 134/2004)