INSTRUCTIONS TO NEW JOINEES:

• This is only a sample form which has been filled with sample data for your understanding.
• As a new joinee, you only to fill sections highlighted as shown below in the blank sheet shared with
you separately.
• In case of any doubts, please contact your induction anchor.

SAMPLE
 FORM – 1
{See Sub Rule (1) under rule of the Tamil Nadu Industrial Establishments
(Conferment of Permanent Status to Workmen) Rules, 1981}
REGISTER OF WORKMEN
(To be Maintained by the employer of Industrial Establishment)

1. Employee No :

2. Name : Ramesh S

3. Address of the Workman : Permanent Address

4. Designation of the Workman : Designation as per offer letter

5. Whether Temporary, Casual, Badli,

or Apprentice (other than those
covered under the Apprentices
Act, 1961) : on probation

6. Date of first entry into service : DOJ ( Today’s Date)

7. Date of which he completed 480 days

of Service :

8. Date on which made permanent :

Signature of the workman with

date

Remarks:
 FORM 1
Nomination and Declaration Form
(See Rule 3)
1. Name of person making nomination : Ramesh S
(in block letters)

2. Father’s/Husband’s Name : Siva ( Father’s Name)

3. Date of Birth : 18/09/1990

4. Sex : Male

5. Marital Status : Married

6. Address
Permanent : Permanent Address

Temporary : Temporary Address

I hereby nominated the person(s)/cancel the nomination made by me previously and nominate the person(s) mentioned below to
receive any amount due to me from the employer, in the event to my death.
Name of Address Nominee’s Date of Total amount of if the nominee is minor,
nominee/ relationship birth share of name
nominees with the accumulations relationship and address of
member in credit to be the guardian who may
paid to each receive
nominee the amount during the
minority of nominee
Shiva Xyz Father 19/09/1970 50%

Shruthi XYz Mother 19/09/1980 50%

1. Certified that I have no family and should I acquire a family hereafter, the above nomination shall be deemed as cancelled.
2. “Certified that my father/mother is/are dependent upon me.
3. *Strike out whichever is not applicable.

Signature or the thumb impression

of the employed person
Certificate by employer
Certified that the above declaration and nomination has been signed/thumb impressed before me by Sri/Smt./Kum
……………………… employed in my establishment after he/she has read the entry/entries have been read over to him/her by
me and got confirmed by him/her.

Signature of the employer or other authorized

Officer of the establishment and designation
Place :
Date :
Name and address of the factory/
Establishment and rubber stamp thereof