Form VII

(See clause (a) of sub rule (1) of rule 36)

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 If the

nominee/nominees relationship of of share nominee is

with the Birth of minor,

employee accumulations name,

in relationship,

credit to be and

paid to address of

each nominee the

guardian

who

may receive

the amount

during the

minority of

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.

* 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/Kum ..............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