ANNEXURE-I

To
The Principal Chief Personnel Officer
CLW/Chittaranjan

Respected Sir,

Sub: Prayer for appointment on compassionate ground for the category of post
of _________________________ in level___________________
***************
I, Smt.____________________________________________ like to inform you that my
husband, Shri_____________________________________, Ex.Designation________________
Ex.T/No.________________ Ex.Employee No.____________________ B.U.No.____________,
working under__________________________ has breathed his last on ____________________
and accordingly his services has been terminated vide office order No._____________________
dated_________________ w.e.f.__________________.
That sir, untimely termination of services due to sudden death of my husband has brought
acute financial hardship to maintain our family which consisting of the following members.
Sl.No. Name Relationship Date of Birth Occupation (If employed,
give details)

Cont’d….P/2
 ANNEXURE-I
Page-2

Particular in respect of the candidate for whom employment is sought for are furnished below:-
1. Name of the candidate:
(Block Letters)
2. Relationship of the candidate with the
deceased employee:
3. Date of Birth (As per school certificate)
4. Educational Qualification:

5. Caste (SC/ST/OBC/UR):
6 Address with Contact Number:

Details of the property owned by the family:

a) Landed Property_______________________________________________________
b) Dwelling House_______________________________________________________
c) Bank/Cash Balance_____________________________________________________

Sir, I pray to your good self to kindly consider my appeal for a suitable employment in
your esteemed organization, as per eligibility of Myself/Son/Daughter for Group – ‘C’/’D’
category for the post of ______________________ in Level___________ on Compassionate
ground as a Bread earner of the family.

Thanking you,

Yours faithfully.

DA:___________

Dated: Signature:___________________________

Name in full_________________________
Address:____________________________

___________________________________
 ANNEXURE-III

Declaration/Undertaking

1) I do hereby declare that the above information and documents furnished

by me are true to the best of my knowledge. In case my
declaration/particulars are not found true at any stage my application will
be treated as cancelled and employment, if provided to the candidate may
be terminated.

2) I also hereby declare that my application dated________ for appointment

of Myself/Son/Daughter (Name_______________________________)
on compassionate ground is the first and only application for this
purpose. No other application in this regard has been submitted earlier
and no other appointment on compassionate ground has been considered
against the same case.

_________________________
Signature of applicant
Name:____________________
Date:_____________________
 ANNEXURE-II

To Passport
The Principal Chief Personnel Officer photograph duly
CLW/Chittaranjan
signed by the
candidate
Respected Sir,

Sub: Prayer for appointment on compassionate ground for the category of post
of _________________________ in level___________________
***************
I, Shri/Smt./Miss_________________________________________widow/son/daughter
of Late/Shri_________________________________________, Ex.Designation______________
Ex.T/No.________________ Ex.Employee No.____________________ B.U.No.____________,
working under__________________________ is hereby submitting my application for
consideration of employment as bread earner of the family on compassionate ground to look
after & maintain the family members properly who are dependent on the Ex.Railway employee
as stated above.
My Bio-Data is given below:-
1 Name of the candidate:
(in block letters)
2 Father’s Name:

3 Mother’s Name:

4 Husband’s Name:

5 Relationship with the deceased

employee:
6 Date of Birth:
(Supporting documents to be attached)
7 Whether SC/ST/OBC/UR (Copy of
caste certificate to be enclosed):
8 Educational Qualification:
(Photocopy of certificates to be attached)
 ANNEXURE-II

Page-2

9 Technical Qualification (if any):

(Photocopy of certificates to be attached)

10 Present occupation:

11 If employed or self employed, details

particulars of the employment:
12 Present Address:

13 Permanent Address (Other than

Railway accommodation):

14 Post & Level applied/prayed for:

15 Any other information:

I therefore, request you to kindly extend your sympathetic consideration to provide

suitable employment as prayed for in your organization in favour of me as a bread earner of the
family on compassionate ground for the survival of the bereaved family.
I do hereby declare that if any employment is being provided by the CLW Administration
to me, I shall maintain the other family members properly who are dependent on the Ex.Railway
employee, otherwise my appointment may be terminated forthwith for neglecting or not being
properly maintained the family members.
Thanking you,
DA: Yours faithfully,
Dated:
Signature:_________________________________
Name:____________________________________
Widow/Son/Daughter of_____________________
Countersigned

Signature of widow spouse/Mother/Father

 ANNEXURE-IV

DECLARATION OF SON/DAUGHTER OF DECEASED EMPLOYEE FOR

“NO OBJECTION TO CONSIDER COMPASSIONATE APPOINTMENT
TO HIS/HER BROTHER/SISTER.
I, Shri/Smt./Miss____________________________________________ Son/Daughter of
Late/Shri/Smt.__________________________________________________________________
Ex.Designation______________________ Ex.T/No._________Employee
No._______________Residing at
___________________________________________________________________
___________________________________________ do hereby declare that I have no objection
if CLW Administration consider the request of compassionate appointment in favour of my
Brother/Sister Shri/Smt./Miss______________________________________________________
consequent on the Death/Medical Unfit / Missing of my father/mother Late/Shri/Smt.
_________________________________________________, as a result his/her service has been
struck off the roll of CLW w.e.f. _________________________________ vide office order/E.O.
No.____________________________________ dated__________________.

Signature with date:_________________________

Full Name:________________________________
Relationship with deceased employed
__________________________________________
Address:__________________________________
__________________________________________
Witness by any two person of the locality:-

1. Signature with date:________________________

Name:___________________________________
Address:_________________________________

2. Signature with date:________________________

Name:___________________________________
Address:_________________________________
 ANNEXURE-VI

Particulars of all family members of the Railway servant

(Name:_____________________________________________________________________)
(If employed, their income and whether they are living together or separately).
Sl. Name(s) Relationship Age Address Employed or no
No. with the (if employed,
Government particulars of
servant employment and
emoluments)

DECLARATION/UNDERTAKING
1. I hereby declare that the facts given by me above are, to the best of my knowledge,
correct. If any of the facts herein mentioned are found to be incorrect or false at a future
date, my services may be terminated.
2. I hereby declare that I shall maintain properly the other family members who have been
dependent (details given above) on Railway servant mentioned above and in case it is
proved at any time that the said family members are being neglected or not being
properly maintained by me further during the period of their dependency my appointment
may be terminated.

Date: (Signature/LTI of the candidate)

Witness: Name:____________________________________

Signature/LTI of applicant Address:__________________________________

Name:____________________________ __________________________________

I have verified that the facts mentioned above by the candidate are correct.

Date: (Signature of the Welfare Officer)

Name:____________________________________

Designation:_______________________________
(Stamp)
 ANNEXURE-V

IDENTITY CERTIFICATE
Passport
photograph
Certified that Shri/Smt./Miss____________________________________ duly signed by the
candidate and
who is the son/daughter/widow of Shri/Late________________________
attested by the
___________________________________________________________ issuing authority

Residing at__________________________________________________
______________________________________________________________________________
is known to me for the last____________ years _______________ months and to the best of my
knowledge and belief that he/she bears respectable character and has no antecedents whichrender
him un-suitable for Government Employment.
The signature and Left Thumb Impression (L.T.I.) of Shri/Smt./Miss_______________________
_____________________________________ are obtained below in my presence and his/her
photograph is pasted above duly attested by me.
Shri/Smt./Miss_____________________________________ is not related to me. This certificate
is being issued to avoid impersonation at the time of employment in Chittaranjan Locomotive
Works, if so offered.
______________________ ___________________________________
Signature of the candidate Signature of the authorized person
Name:______________________________
_______________________ Designation with seal__________________
L.T.I. of the candidate

______________________________________
L.T.I./Signature of the Father/Mother/Guardian
Full Name:_____________________________
N.B.:-
(A) Certificate to be signed by the following authority when the candidate is residing at Chittaranjan.

1. Area committee members concerned.

2. Vice Warden concerned
3. Gazetted officer.

(B) Certificate to be signed by the following authority when the candidate is residing outside Chittaranjan.

1. BDO
2. C.O.
3. Chairman of Municipal Corporation
4. Gazetted officer
5. Doctor of the locality
6. Mukhiya/AnchalPradhan of the locality.