Emp No: 90xxxxx

Date of Joining: DD/MM/YYYY

Form 1

Nomination & Declaration Form

Name (in Block Letters) SXXTX DXXVXL KXDXM (As per Aadhar card)

Father's/Husband's Name DXXVXL KXDAX

(in case of married woman)
Date of Birth DD/MM/YYYY

Gender (Male/Female) Female

Marital Status Mxxxixd

Mention permanent address

Permanent Address

Mention present address

Present Address

Version 1.2
I hereby nominate 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 of my
death.
Name of the Address Nominee's Date of Total amount If the
nominee/ nominees Relationship Birth of share of nominee is
with the accumulations minor:
member in credit to be name,
paid to each relationship
Nominee and address
of guardian
who may
receive the
amount
during the
minority of
nominee

Nominee Name in case Spouse/Parent Spouse/Parent Spouse/parent 100% (Distribute NA

of married Spouse or Address s DOB portion among all
parents name nominee)

Nominee Name in case Father Address Father Father DOB 50% NA

of unmarried Father
Name (In case parents
are not alive can give
guardian or siblings)

Nominee Name in case Mother Address Mother Mother DOB 50% NA

of unmarried Mother
Name(In case parents
are not alive can give
guardian or siblings)

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.

*Strike out whichever is not applicable

Version 1.2
 Paste scanned signature

Signature/Thumb Impression of the employee.

CERTIFICATE BY EMPLOYER

Certified that the above declaration and nomination has been signed/thumb impressed before
me by Shri/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

Version 1.2