Form X

[see rule 37]

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

nominee/nominees relationship of share of is minor, name,

with the Birth accumulations relationship, and

employee in credit to be 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/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