FORM ‘H’
[SEE SUB-RULE (4) OF RULE 6]
MODIFICATION OF NOMINATION

To……………………………….
[Give here name or description of the establishment with full address]
I, Shri/Shrimati /Kumari………………..[Name in full here] whose particulars are given in the statement below, hereby give notice that the nomination filed by me on………….[date] and recorder under your reference No…………..dated……….shall stand modification in the following manner:
[Here give details of the modifications intended]
STATEMENT
1. Name of the employee in full.
2. Sex.
3. Religion.
4. Whether unmarried/married/widow/widower
5. Department/Branch/Section where employed.
6. Post held with Ticket No. or Serial No., if any.
7. Date of appointment.
8. Address in full.                     
Place                                                                Signature/Thumb impression
Date                                                                 of the employee.
                       
DECLARATION BY WITNESSES
Modification of nomination signed/thumb impressed before me.
Name in full and full address                                          Signature of witnesses
of witnesses
1.                                                                                 1.
2.                                                                                 2.
Date
Place
CERTIFICATE BY THE EMPLOYER
Certified that the above modifications have been recorded.
Employer’s reference No., if any.           Signature of the Employer/Officer authorised.
                                                             Designation
                              Name and address of the establishment or rubber stamp thereof.
ACKNOWLEDGEMENT BY THE EMPLOYEE
Received the duplicate copy of the notice for modification in Form ‘H’ filed by me on duly certified by the employer.
Date                                                                                        Signature of the employee
Note:    Strike out the words not applicable.