FORM-2 (Revised) NOMINATION AND DECLARATION FORM FOR EXEMPTED / UNEXEMPTED ESTABLISHMENTS _tamdon and Neniston Form Under the Epes rvident Fn Employes! Penson Scheme (uerPNS 86 tbe taps Potente earn 18 clk ployer Psion She, 1985) . 1 Name in Bock Letters Reson kya 2 Fathers / Husband's Name : ES CNG b 3 Date of Bich OR=o1_ tagp 4 Sex Mabe 9 Marita Sane » _MARRrEeD § Acsoun Namie a | 7 Address Permanent L=- D2/ éF, iY Flay Temporary ne $Date of Joining by mE aS Nene mete | Newiecr dala [Basal] —Foataacas olaareat ie nono Bminorname Nemow/ Nemines ( waththementer | sich | oul onin provident ‘dress & etaonship of e Asdiatemidionchoariee | pudanwhengy meine eury i z z < 5 oeengh Father [55 foo “f. ca | oa a 1 nce hat Nave no family as defined in par 2 (othe _inPlove's Provident Fund Scheme 1952 and should f Saute fily hereafter the shove nomination shale ees as cancelled Gate hat my father / mother i / ace depended upon me amarsod members in the absence of dependent pareve ‘may nominate any other person to receive the shares 'o/her marriage and any nomisation made Welan ee ‘marrige shal be deemed to be invalid pression ofthe SubscriberPART-8 (EPs) srgeky furnish Below particulars ofthe members of my family who would be ligible to receive widow /chiléren pension inthe event of my death [SNe] Name ofthe Family Wentos Address Date of Birth] Relationship Dine singly RESPIR RUE ee | peg Sein hat have no family as dein in pra 2 (ui) ofthe Employee's Pension Scheme 1995 and should I acquire a family hereafter the above nomination should be deemed as concede (ib imeee mints te following person for receiving the monthly widow pension (admisibe under Para 162) (g) () & (Gin the event of my death with out leaving any ell igible family member for receiving pension. Name & Address of rtm: Date of Birth Relationship with the member Divsh Sip es New Deb’ = jooys 55 Fat Date : x MAD Signature / Thus iecssion ofthe subserter CERTIFICATE BY EMPLOYER \Certified thatthe above declaration and nomination hhas been signed/thumb is peewee employed in my establishment after he/she hee eed him/her by me and got confirmed by him/her spressed before shri/Smt/Kum the entry entries have been read over tl Pace: ‘Siratareof he empayer Name & Ades of te Etim