- (FORM 2 REVISED) ED NOMINATION AND D LLARATION FORM, FOR UNEXEMPTEDLEEMPTED. DESAAT STABLISHMENTS peclaration ane! Nomination Form under the Employees Provident Funds & ‘Employees Pension Schemes (Porograph 33 and 61 (1) ofthe Employees Provident Fund Serene 1952 & Paragraph 18 of the Employees Pension Scheme 1995) 1. Name (IN BLOCK LETTERS) : GIRIE IT OM. . —— Name ‘iors jtusbaneds lame” Sumame Se eiaice LOG L LER L. PEN END mrncnmmn BLEED. 5, Marital Status ../22. Sbuns.62,.pnasrated 4, *Sext MALE/FEMALE:,,. 0.2L A 6, Address Permanent / Temporary: 2/L2.bick. Bla lenprlayar = CY2/02 AI EPI Neger : the nomination made by me previously and nominate it in the Employees Thereby nominate the person (s)/ cancel the amount standing to my cred the person (s) mentioned below to receive Provident Fund, In the event of my death. _ ' camer ene A Nominee's share of fc ae Name ofthe ‘Mavonehip | Date of | accumulations in Nominee (5) ‘aadress atlonstip | OO" | Provident Funds | ee cut member Tobe paid to | Tene oy each nominee | “of the nominee T z zi a 5 [ 6 | Fa ya/aiegZ//04-10/ Se ** lo2 yale 161, ancamota'ag a wile yo /09 bf: he C4 2/39 G69 1. * Certified that I have no family as defined in para 2 ( (g) of the Employees Provident Fund Sche 1952 and should I acquire a family hereafter the above nomination should be deemed ascanceled, Orr Signature/ or thumb impression Of the subscriber 2, *Certified that my father/mother is/are dependent upon me. Strike out whichever is not applicablePART — (EPS) Para 18 y Children Pension in the event of my premature deal in service. hereby furnish below particulars ofthe members of my family who would be eligible to recelve widow) Relationship with Ne Name & Address ofthe Family Membe a eee ee Jayalak$nrey G. ) lene SI hab? ,Aaaamels) a Cc bentedac 642109. Lhaya% : 2 bpowr9, Us obo, pras net Me Cond a2 6219-9 Rayashree. biegee pine, goege nad | 3) { the member, sion Scheme 1995 in para 2 (vil) of the re arly as defined rt ‘shall furnish Particul Certified that I have family hereafter T and should T acquire @ {hereby nominate the fllowing person for receiving the monthly widow 1e Employee's Family Pen: ars there on in the above form. leaving any eligible family mer pension (admissible under para 16 smber for receiving pension. Bea) C&C in the event of my death without ‘Name and address of the nominee Date of Birth Relationship with member [Jaye lak shia -G Poe : Lia iai G/G 79062 pec “yp te niger, lAnnaneler oo . ews J9E LE 22 SSignature/ or thumb impression Of the subscriber CERTIFICATE BY EMPLOYE! Certified that the above declaration and nomination has been ime by Shri/Smt./Miss. he/ she has read the entries/ the entries have been read confirmed by him/her. Dat signed / thumb impressed before employed in my established after over to him/her by me and got Signature of the employer or other authorized Officer of the Establishment ‘Name & address of the Factory /Establishment Place: Date: