Form VI

[See Rule 19 (4)]

Modification of Nomination

(Strike out the words not applicable)

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 filled by me on date

………… and recorded under your reference No…………….dated shall stand modified in the

following manner-

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 No. or Serial No., if any

7. Date of appointment

8. Permanent address:

Village…………………. Thana……..……………… Sub-division…………………

Post-Office…………………………

Pin-Code…………District…………………State…………………………… E-mail

ID…………………………………Mobile Number……………………

Place:

Date:

Signature/Thumb-impression of

the Employee

DECLARATION BY WITNESSES

Modification of nomination signed/thumb impressed before me. Name in full and full address

of witnesses. Signature of witnesses

1.

2.

Place Date

Certificate by the Employer

Certified that the particulars of the above nomination have been verified and recorded in this

establishment. Employer's Reference No., if any

Signature of the employer/Officer

authorised Designation

Date:

Name and address of the establishment

or rubber stamp thereof.

Acknowledgement by the Employee

Received the duplicate copy of the notice for nomination in Form-VI filed by me and duly

certified by the employer.

Date: …………………. Signature of the Employee