BEXIMCO CHEMICAL DIVISION - BEXIMCO PHARMACEUTICALS LIMITED

BPL HRM FORM 002-01

Photograph
of
NOMINATION FORM Employee
For Gratuity, Provident Fund and Other Employment Benefits

I, ............................................................................... D/O or S/O................................................................... Bearing

Employee Number ..................... of Beximco Pharmaceuticals Ltd. do hereby nominate the following relative(s) to
receive, in the event of my death, the amount that may stand to my credit in the following manner shown against
his/her/their name(s).

Nominee (1) Information Nominee (1) Photo

Name % of Share

Contact No. Relationship

NID/ Birth
Nominee (1)
Certificate
Signature
Number

Address

Nominee (2) Information Nominee (2) Photo

Name % of Share

Contact No. Relationship

NID/ Birth
Nominee (2)
Certificate
Signature
Number

Address

Date ................................... --------------------------------

Signature of the Employee

BPL HRM FORM 002-01 Page 1 of 2

 BEXIMCO CHEMICAL DIVISION - BEXIMCO PHARMACEUTICALS LIMITED

BPL HRM FORM 002-01

NOMINATION FORM

For Gratuity, Provident Fund and Other Employment Benefits

Nominee (3) Information Nominee (3) Photo

Name % of Share

Contact No. Relationship

NID/ Birth
Nominee (3)
Certificate
Signature
Number

Address

Nominee (4) Information Nominee (4) Photo

Name % of Share

Contact No. Relationship

NID/ Birth
Nominee (4)
Certificate
Signature
Number

Address

Date ……………………. --------------------------------

Signature of the Employee
WITNESS: The Nomination Form is signed in presence of:
Name: ..................................................................................………………................................................
Address: .................................................……………….............................................................................
Signature: ................................................ Date: ..................................... Tel: ............................................

Name: ..........................................................................………………........................................................
Address: .................................................……………….............................................................................
Signature: ................................................ Date: ..................................... Tel: ............................................

Note: Please attach one copy of NID Card/Birth Certificate of each nominee with this form.

BPL HRM FORM 002-01 Page 2 of 2