Application for Haryana Roadways Bus Pass

1. Name:

2. Father's/ Husband’s Name:

3. Address:

4. Phone No. (if any):

5. Route:

6. Duration of Pass:

7. Attached photocopy as Photo Identity Proof is

Declaration: The above information provided by me is true and correct and I shall be fully responsible for the same, if it is found incorrect at any stage and legal action can be initiated against me.

(Signature of Applicant)

Affiix one recent passport size

(35mm x 45 mm)colour photo here.

Sign withing boxfor scanning purpose.

to From

Office ID CardVoter ID Card

PAN Card

Driving Licence

Passport

Ration Card

Other :

Note: This bus pass is valid only in ordinary buses including 'Haryana Uday'.

1. Single fare for station to = Rs.

2. Total fare for journeys opted in Sr.No. 6 above = Rs.

3. Amount deposited vide receipt No. Date

4. Issued vide Pass No. Date

Pass Clerk Cashier Authorised Signatory (Full Name) (Full Name) (With Seal)

FOR OFFICE USE ONLY

(please mark ( ) tick in the appropriate box)

for further information or download application form please log on to

(One Month/ Three Months/ Six Months)