FORM 'F'

[See sub-rule (1) of rule 6]

Nomination
To ..
[Give here name or description of the establishment with full address]
I, hri!hrimati!"umari . whose particulars are #iven in the statement below,
[$ame in full here]
hereb% nominate the person(s) mentioned below to receive the #ratuit% pa%able after m% death as
also the #ratuit% standin# to m% credit in the event of m% death before that amount has become
pa%able, or havin# become pa%able has not been paid and direct that the said amount of #ratuit%
shall be paid in proportion indicated a#ainst the name(s) of the nominee(s)&
'& I hereb% certif% that the person(s) mentioned is a!are member(s) of m% famil% within the
meanin# of clause (h) of section (') of the (a%ment of Gratuit% )ct, 1*+'&
,& I hereb% declare that I have no famil% within the meanin# of clause (h) of section (') of the
said )ct&
-& (a) .% father!mother!parents is!are not dependant on me&
(b) m% husband/s father!mother!parents is!are not dependant on m% husband&
0& I have e1cluded m% husband from m% famil% b% a notice dated the to the 2ontrollin#
)uthorit% in terms of the proviso to clause (h) of section ' of the said )ct&
6& $omination made herein invalidates m% previous nomination&
Nominee(s)
$ame in full with full
address of nominee(s)
3elationship with the
emplo%ee
)#e of nominee (roportion b% which
the #ratuit% will be
shared
1&
'&
,&
so on&
Statement
1& $ame of emplo%ee in full&
'& e1&
,& 3eli#ion&
-& 4hether unmarried!married!widow!widower&
0& 5epartment!6ranch!ection where emplo%ed&
6& (ost held with Tic7et or erial $o&, if an%&
+& 5ate of appointment&
8& (ermanent address&
9illa#e Thana ub-division . (ost :ffice
5istrict . tate
(lace i#nature!Thumb impression
5ate of the emplo%ee
Declaration by witnesses
$omination si#ned!thumb impressed before me&
$ame in full and full i#nature of witnesses&
address of witnesses&
1& 1&
'& '&
(lace
5ate
Certificate by the employer
2ertified that the particulars of the above nomination have been verified and recorded in this
establishment&
;mplo%er/s 3eference $o&, if an%&
i#nature of the emplo%er!
officer authorised
5esi#nation
5ate $ame and address of the
establishment or rubber stamp
thereof&
Acknowledgement by the employee
3eceived the duplicate cop% of nomination in <orm /</ filed b% me and dul% certified b% the emplo%er&
5ate i#nature of the emplo%ee