Form VI

[SEE RULE 7 (2) (4)]

MODIFICATION OF NOMINATION

To …………………………………………………………………………………….

[Give here name or description of the establishment with full address]

I, Shri/Shrimati/Kumari……….…………[Name in full here] whose particulars are given in

the statement below, hereby give notice that the nomination filed by me on

……………….… [date] and recorded under your reference No.

…………….dated………………shall stand modified in the following manner. [Here give

details of modifications intended]

STATEMENT

1. Name of employee in full.

2. Sex.

3. Religion.

4. Whether unmarried/married/widow/widower.

5. Department /Branch/Section where employed.

6. Post held with Ticket or Serial No. if any.

7. Date of appointment.

8. Address in full.

Place Signature/Thumb impression of the employer

Date

DECLARATION BY WITNESSES

Modification of nomination signed/thumb impressed before me.

Name in full and full address of witnesses. Signature of witnesses

1. 1.

2. 2.

Place

Date

CERTIFICATE BY THE

EMPLOYER

1. Certified that the above modification have been recorded.

2. Employer’s Reference No., if any.

Signature of the employer/ officer authorized

Designation

Name and address of the Establishment

or rubber stamp thereof.

ACKNOWLEDGMENT BY THE EMPLOYEE

Received the duplicate copy of the notice for modification in Form ‘H’ filed by me

on………….duly certified by the employer.

Date Signature of the employee

Note