Photograph of

nominee(s) to be
signed by the Nominee form
employee

I, Mr./Miss/Ms. S/D/W of , E mployee ID , employee of Augmedix

Bangladesh Limited hereby nominate the person(s) mentioned below to collect the amount under all the benefit s scheme as per company policy in the event of
my death, my life exigency, insanity etc.

Percentage (%) of the amount to be paid

Name if the nominee is
Date of birth All other benefits a minor to whom the Signature/Thumb
Name & Address of the nominee Relationship
(dd/mm/yy) Group Life (Gratuity/Leave payment to be made on print of the nominee
insurance claim encashment etc.) as per his/her behalf
company policy

Signature of the employee Witness Signature

Date: (Family member/Colleague/friend)
Name:
Date:

Note: Please attach 1 (one) passport size photograph and a copy of any photo ID for each nominee