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(NOMINATION AND DECLARATION FORM)

FOR U%EXEMFT ED EXEMPTED ESTABLISHMENTS)

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Father’s Husband’s Name

3 c2ji Cg Date of Birth
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larital Status
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7. ips.esf Address jt6 (Permanent) : b-rsr9cb (Temporary)

6 t3 Date of joining
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I hereby cancel tho rumination made previously and nominate, the person(s) mentioned below to receive the amount standing
to mo credit in the Employee’s Pros dent Fund, in the event of my death.
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