Statement

Name of employee in fu ll
Sex. MALE
3 Religion. H[NDU
4 Wheth er unmaried/ married/ widow/ widower.
5 Department/ Bran ch/Section where employed. pUNé
6 Post held with Ticket or Serial No., if any.
7 Date of appointment. 24 l06 l024
8 Perman ent address.
Village.fSASHPIS..Thana.NHK.....Sub-divis ion .N.HLX..Post Office... AMok ysGK

Place NsHeN SianAeumb impression

of the employee
Date y| O4 1n01|

Declaration by w itnes ses

Nom in ation signed/ thu mb impressed before me.

Name in full and full Sign atu re of witn esses

1 1.
2 2.

Place
Date

Certificate by the emp loy er

Certified that the particu lars of the above nomin ation have been verified and
recorded in this establish ment.

Employer's Referen ce No., if any

Sign ature of the employer/
Officer au thorized

Design ation

Date Name and address of the

Establish ment or rubber stamp
thereof.

Acknow le dgement by the employee

Received the duplicate copy of nom in ation in Form F' filed by me and duly
certified by the employer.

Date 24104 12oy Signata e of the employee

Samurum HESW.rstS(WM$ (ae1CMATLTTYFRM FIN) ake