Gate Pass cum Attendance Sheet http://www.onlinedlwinternship.in/FinalPrintStudentform.

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Gate Pass
SSE / Concerned

Please arrange practical training in marked areas and send attendance sheet duly signed.Please also ensure that the
trainee should be equipped with PPE's( safety helmet & shoes etc.)

Registration No.

Name

Father Name

Email

Date of Birth

Mobile No.

Branch Name

College Name with city name

Year in Studying

Training Month

Training Duration(In weeks)

FOR OFFICE USE ONLY :

Training Time * Morning After Noon

Training Date * From. To.

Training Area * ......................................................................................................................................

Signature Of Training Incharge

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Annexure-I

FORMAT FOR DECLARATION BY INTERNS

1. With reference to the offer for internship vide letter No. .................................................. dated........................., I hereby undertake the following: -
2. I will be doing internship from ................................... to .................................. at Diesel Locomotive Works (DLW), Varanasi.
3. I am not entitled to any remuneration in the form of stipend, salary or allowances of any kind by the DLW. I am also not entitled to any pass or PTO from
Indian Railways.
4. I would abide by all General rules and regulations of discipline and conduct at the DLW, Varanasi.
5. I am liable to compensate to the DLW for any loss or damage to equipment and fittings that may be caused during the course of training in workshops etc.
6. I would not be treated as employee of Indian Railways and as such will not be entitled to any compensation or damage from the DLW for any injury to me
or to my property etc.
7. I agree to be under the administrative control and discipline of the Technical Training Centre, DLW, Varanasi.
8. I will not claim any advantage for employment in Indian Railways in future on the basis of the internships.

Date:.....................................

Name: ....................................

Institute: ...............................

Course: ..................................

Declaration by the Guardian / Parent

........................................................ undertakes to indemnify DLW, Varanasi for any loss or damage to equipment and fittings that may be caused by Mr/Ms (
............................ during his/her internship with Indian Railways.

(Authorised Signatory/Signature of Guardian)

Name of the Guardian / Parent:.

Relation with Trainee (Son/Daughter/Other Please Specify)........................

Address of the Guardian / Parent:.

Contact No. (Mobile / Landline).....................................................................

E-mail (if any).....................................................................................

Name of Trainee : ABHIMANYU SINGH Registration No. : TTC/DLW/17/1457

Training Month : JUNE Branch Name : CIVIL ENGINEERING

Declaration for Internship (by trainees)

I hereby declared that: -
1. I always use safety equipments like safety helmet, safety shoe, and lab coat (for ladies) during training which will be arrange by me.
2. As I entered in DLW premises, I will follow the all rules and bylaws of training.
3. As a vocational trainee, I will not harm the DLW properties.
4. During training period, I will follow the instructions given to me by the instructors / training in-charge.
5. I will attend the training regularly.
6. I will never interrupt the work by gathering with other trainees.
7. This is well known to me that if I do indiscipline by my activity, this will be intimated to my guardian and institute.
8. This is well known to me that my training can be postpone / prepone / curtail or cancel on any time by the DLW administration.
9. I will follow the rules of DLW for quality, environment, health and safety management.
10. In DLW premises especially in workshop, I will do training on my own risk and no any compassion claim shall be done by me in case of any
accident / casualty.

Candidate Signature

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Name of
Branch Name
trainee
First Week: Shop Name
Day . . . . .
Date
Signature of
concerned
SSE/SSO Full name & seal of SSE/SSO
Second
Shop Name
Week:
Day
Date
Signature of
concerned
SSE/SSO Full name & seal of SSE/SSO
Third Week: Shop Name
Day
Date
Signature of
concerned
SSE/SSO Full name & seal of SSE/SSO
Fourth
Shop Name
Week:
Day
Date
Signature of
concerned
SSE/SSO Full name & seal of SSE/SSO
Fifth Week: Shop Name
Day
Date
Signature of
concerned
SSE/SSO Full name & seal of SSE/SSO
Sixth Week: Shop Name
Day
Date
Signature of
concerned
SSE/SSO Full name & seal of SSE/SSO

Note : Entry in workshop on Saturday is not allowed due to half day working Only administrative works can be done(if required) at TTC on
this day.

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Student Acknowldgement

Name of Trainee : ABHIMANYU SINGH Registration No. : TTC/DLW/17/1457

Training Month : JUNE Branch Name : CIVIL ENGINEERING

Note :

1. Student will send filled form alongwith declaration form to the following address through simple post/ courier/registers post/ by hand

Principal
Technical Training Centre
Diesel Locomotive Works,Varanasi-221004

2. Check list for papers to be send

a. Gate Pass

b. Attendence Sheet

c. College Request letter(in original)

d. Declaration by Intern and Guardian/Parent

e. If Trainee is Railway Employee dependent. He/She bring a attested photocopy of privilage/school pass

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