Emp No: 9048875

Date of Joining: 25th/January/2022

Form 1

Nomination & Declaration Form

Name (in Block Letters) SHRIDHAR BAJARANG BHOSALE

Father's/Husband's Name BAJARANG RAMCHANDRA BHOSALE

(in case of married woman)
Date of Birth 22th/august/1992

Gender (Male/Female) Male

Marital Status Unmarred

At Bhosalewadi Post Korti Tel Karad Dist Satara Pin Code 415109
Permanent Address

Plot No 41, Near Sunflower School, Jambe Road,Pimpri-Chinchwed, Pune

Present Address 411033

Version 1.2
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 the Address Nominee's Date of Total amount If the
nominee/ nominees Relationship Birth of share of nominee is
with the accumulations minor:
member in credit to be name,
paid to each relationship
Nominee and address
of guardian
who may
receive the
amount
during the
minority of
nominee

Bajarang Ramchandra At Bhosalewadi Father 20/Apr/1968 50%

Bhosale Post Kori Tal Karad
Dist Satara 415109

Sulochana Bajarang At Bhosalewadi Mother 17/Apr/1974 50%

Bhosale Post Korti Tal Karad
Dist Satara 415109

1. Certified that I have no family and should I acquire a family hereafter, the above nomination shall
be deemed as cancelled.

2. Certified that my *father/mother is/are dependent upon me.

*Strike out whichever is not applicable

Signature/Thumb Impression of the employee.

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 CERTIFICATE BY EMPLOYER

Certified that the above declaration and nomination has been signed/thumb impressed before
me by Shri/Smt/Kum Shridhar Bajarang Bhosale employed in my establishment after he/she has
read the entry/entries have been read over to him/her by me and got confirmed by him/her.

Signature of the employer or other authorized

Officer of the establishment and Designation

Place: Pune

Date: 25/January/2022 Name and Address of the

factory/Establishment and rubber
stamp thereof

Version 1.2