Form 19

{See sub-rule (2) of Rule-64}

Nomination Form

This nomination is being done on the ……………… (date) day of …………………….. (month)

……………………. (year).

I, …………………………….. son/ daughter of ……………………………. hereby require that in

the event of my death before resuming work, the balance of my pay, due for the period of leave with wages

not availed of shall be paid to …………………………….. who is my ……………………………

(relation).

Witness:

(1)

Signature-

Name-

Address-

Identity proof number-

(2)

Signature-

Name-

Address-

Identity proof number-

Signature and address of the employee