FORM I
[See sub-rule (1) of rule 3]
NOMINATION

To
(Give here name and address of employer together with name and full address of the establishment)
I.................................................................................................................
(name in full here)
whose particulars are given in the statement below, hereby nominate the person mentioned below to receive all amounts payable to me as wages, if such amounts could not or cannot be paid on account of my death before the payment or on account of my whereabouts not being known.
2. I hereby certify that the person nominated by me is a member of my family within the meaning of Cl. (e) of rule 2.
3. I hereby declare that I have no family within the meaning of Cl. (e) of rule 2 and if I acquire a family hereafter. the above nomination shall be void and in that event I shall make a fresh nomination in Form 11.
4.        (a) My father/mother/parents/is/are not dependent upon me.
(b) My husband's father/mother/parents/is/are not dependent on my husband.

Nominee
Name and address of the nominee	Nominee’s relationship with the employed person	Age of Nominee
1	2	3
	Statement

 1. Name of the employed person in full:
2. Sex
3. Religion:
4. Whether unmarried/married/widow/widower:
5. Department/Branch/Section where employed
6. Post held with ticket number of serial number, if any:
7. Date of appointment:
8. Present address:
9. Permanent address:
Village………………..Thana………. Sub-Division………… Post Office……… District ……….. State…………..
Place……………
Date…………..
Signature/thumb-impression
of the employed person
Declaration by witnesses.
Nomination signed/thumb-impressioned before me.
Signature of witnesses
Name in full and address
1                                                          1
2                                                          2                     
Place………..
Date……….
(Certificate by the employer)
Certified that the particulars of the above nomination have been verified and recorded in the register of nominations in Form IV at Serial Number………………………………………….
Signature of the employer/
Officer authorised.
Designation
Name and address of the
establishment or rubber stamp thereof.
Date ………….
Place……………
Acknowledgment of the employed person
Received the duplicate copy of the nomination in Form I filled by me and duly certified by the employer.
Place
Date                                                   Signature of the employed person
Note : Strike out the words and paragraphs not applicable.