FORM ‘H’

 

[See sub-rule (4 ) of rule 6 ]

 

To ………………………………………………………………………………………………….. [Give h ere n a m e or description of the establishment with full address ]

1. Shri/ Shrimati/ Kumari  ……………[Na m e in full h ere] whose particulars a re given in the statement below, hereby give notice that the nomination filled by m e on [date] and recorded under  your  reference No. ……………… dated  …………….. s h a ll s tan d  modified  in the following manner:

 

[Hear give details of the modifications in tended]

 

State m e n t

 

1	Na m e of the employee in full.
2	Sex.
3	Religion .
4	Whether unmarried/ married/ widow/ widower.
5	Department / Bra n ch / Section where employed.
6	Post held with ticked No. or Serial No., if a n y.
7	Date of appointment .
8	Address in full.

Place                                                                                       Signature/  Thumb impression

Date                                                                                         of the employee

 

Declaration by witnesses

 

Modification of n om in a t ion signed/ thumb impressed before me. Name in full and full Signature of witnesses. Address of witnesses .

1 .                                                                     1 .

2 .                                                                     2 .

Place Date

 

Certificate by the employ er

 

Certified that the above modification have been recorded.

Employer,s reference No., if any.                                      Signature of the employer/ Officer authorized

Designa t ion

Name and address of the