FORM I

[See sub-Rule (1) of Rule 7]

APPLICATION FOR GRATUIIY BY AN EMPLOYEE

To

Sir/Gentlemen,

            I beg to apply for payment of gratuity to which I am entitled under sub-section (1) of Section 4 of the Payment of Gratuity Act, 1972 on account of my Superannuation/ retirement/ resignation after completion of not less than five years of continuous service total disablement due to accident/total disablement due to disease with effect from the ____________________ Necessary particulars relating to my appointment in the Establishment are given in the statement below:

STATEMENT

1.      Name in full

2.      Address in full

3.      Department/ Branch/ Section where employed

4.      Post held with Ticket or Serial No. if any

5.      Date of appointment

6.      Date and cause of termination of service

7.      Total period of service

8.      Amount of wages last drawn

9.      Amount of gratuity claimed

2. I was rendered totally disabled as a result of ________________________________.

3. Payment may please be made in cash/ open or crossed Bank Cheque.

4. As the amount of gratuity payable is less than Rupees One Thousand. I shall request you to arrange for payment of the sum due to me by

     Postal Money Order at the address mentioned above after deducting Postal Money Order commission there from.

Yours faithfully,

Place:                                                                                                                              Signature/ Thumb-impression

Date :                                                                                                                               of the applicant-employee