Village ............................ Thana ............................ Sub-division ............................ Post Office ............................ District ............................ State............................

Place..........................................

Date...........................................

................................

Signature/Thumb impression of the employee

Declaration by witnesses

Nomination signed/thumb impressed before me.

Name in full and full address of witnesses.

Signature of witnesses.

1...........................................................

1.

...........................................................

2.

..........................................................

2.

...........................................................

Place................................

Date.................................

Certificate by the employer

Certified that the particulars of the above nomination have been verified and recorded in this establishment.

Employer's Reference No., if any.

................................................

Signature of the employer/officer authorised

Designation

Name and address of the

establishment or rubber stamp thereof.

Date :

Acknowledgement by the employee

Received the duplicate copy of nomination in Form 'F' filed by me and duly certified by the employer.

Date :...................................

.......................................

Signature of the employee

FORM 'G'

[See sub-rule (3) of rule 6]

Fresh Nomination

To

...................................................................................................... (Give here name or description of the establishment with full Address)

I, Shri/Shrimati ............................... [Name in full here] whose particulars are given in the statement below, have acquired a family within the meaning of clause (h) of section (2) of the Payment of Gratuity Act, 1972 with effect from the ............................. (date here) in the manner indicated below and therefor nominate afresh the person(s) mentioned below to receive the gratuity payable after my death as also the gratuity standing to my credit in the event of my death before that amount has become payable, or having become payable has not been paid direct that the said amount of gratuity shall be paid in proportion indicated against the name(s) of the nominee(s).