SOUTHERN RAILWAY

( ) G.22 (Revised)

CERTIFICATE

APPLICAATION FOR PRIVILEGE PASS/PRIVILEGE TICKET ORDER I certify that the relatives for whom Privilege Pass/PTO are required is/are residing with and wholly dependent upon me and no brother of mine is obtaining Privilege Pass/PTO for this relative. MY FATHER IS NOT ALIVE . . . . . .. . . . . . . . . . . . . . . . Station employed at . . . . . .. . . . . . . . . . . . . . . .. . . . . . Date . . . . .. . . . . . . . . . . . . . . .. . . . Signature of applicant . . . . .. . . . . . . . . . . . . . . .. . . . . . Name . . . . .. . . . . . . . . . . . . . . .. . . . . . Designation . . . . .. . . . . . . . . . . . . . . .. . . . . . Office . . . . .. . . . . . . . . . . . .. . . . . T.No. Rate of pay

I hereby apply for single/return journey Privilege Pass/P.T.O. as below subject to the Railways regulations and conditions relating to Privilege Pass/P.T.O. and declare that it is/they are for the use of the person/persons mentioned below and I hereby agree to indemnify the Railways over whose lines the same is/are available against any claims made upon them by, or on behalf of any person using such Pass/P.T.O.

Description of Persons shown by tick () for whom Pass/P.T.O. Tickets are required Full tickets All over 12 years Half tickets. All over 5 and under 12 years. (1) (3) (4) (5) Self Wife/Husband Mother or Step-mother , widowed Sisters or step-sisters, unmarried/widowed Daughters or Step-daughters or adopted daughters, unmarried/widowed/married under 18 years Sons or step sons or adopted son under 21 years/over 21 years attending school/college or invalid ( ) Brothers or step brothers under 21 years/over 21 years /over 21 years attending school/college or invalid Nurse or governess or guardian Attendant employed on the regular basis in the person service . . . . . . . . . . . . . . . . . . . . . . .. Outward journey From . . . . . . . . . . . . . . . . . . . . . . .. Inward journey Class to which entitled From ............ Railway ........................ .. . Break journey at ( For free pass only ) Date from which required To

Age

. . . . .. . . . . . . . . . . Date of appointment . . . . . .. . . . . . . . . . . . . . . . Date of retirement

We certify that to our knowledge, the parties for whom Privilege Pass/PTO are required are as described on the reverse. . . . . . .. . . . . . . . . . . . . . . . Signature . . . . . .. . . . . . . . . . . . . . . . Designation . . . . . .. . . . . . . . . . . . . . . . Department . . . . . .. . . . . . . . . . . . . . . .. . . . . . . . . . Foreign line . . . . . .. . . . . . . . . . . . . . . . Signature . . . . . .. . . . . . . . . . . . . . . . Designation . . . . . .. . . . . . . . . . . . . . . . Department . . . . . .. . . . . . . . . . . . . . . .. . . . . . . . . . Home line

( ) ( )

. . . . .. . . . . . . . . . . . Certified that the applicant during the year has had Sanctioned . . . . . .. . . . . . . . . . . . . . . . . . . . . Pass Clerk

Pass/P.T.Os. . . . . .. . . . . . . . . . . . . . . . Issuing Officer

. . . . . . . . . . . . . . . . .. . . . . ....... ........ . ...... To

Pass/P.T.Os No. ........... Route

issued and noted on Index Card.

( ) Signature of thumb impression of the recipient (If at the same station where it is issued)

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