Form VII

(See rule 38)

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 of Total amount If the nominee is

nominee/nominees relationship Birth of share of minor,

with the accumulations name,relationship,

employee in credit to be and address of the

paid to each guardian who

nominee 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.

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/entriesor 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