Form VII

(See clause (a) of sub rule (1) of rule 45) NOMINATION

FORM

1. Name of person making nomination:

(In block letters):

2. Father's/Spouse's Name:

3. Date of Birth:

4. Sex:

5. Marital Status:

6. Address:

Permanent:

Temporary:

I hereby nominate the person(s)/cancel the nomination made by me previously and nominate the person(s)

mentioned below to receive any amount due to me from the employer in the event of my death:-

Name of Address Nominee's Date Total amount of If the nominee is minor, name,

nominee/nominees relationship of share of relationship, and address of the

with the Birth accumulations in guardian who may receive the

employee credit to be paid to amount during the minority of

each nominee nominee

(1) (2) (3) (4) (5) (6)

1. Certified that I have no family and if I acquire a family hereafter, the above nomination shall be deemed as

cancelled.

2. Certified that my father/mother is/are dependent upon me.

3. Strike out whichever is not applicable.

Signature or the thumb impression of the employee

CERTIFICATE BY EMPLOYER

Certified that the above declaration and nomination has been signed/thumb impressed before me by Shri/Smt/Ku

................................................... employed in my establishment after he/she has read the entry/entries or

have been read over to him/her by me and got confirmed by him/her in either of the cases. Signature of the

employer or other authorised officer of the establishment and Designation Place:

Date:

Name and Address of the Factory/Establishment and rubber stamp thereof

ACKNOWLEDGEMENT BY THE EMPLOYEE

Received the duplicate copy of nomination in Form-VIII filed by me and duly certified by the employer. Date:

Signature of the Employee