FORM 'H'

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



Modification or 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 recorded under

your reference No………. dated ……………… shall stand modified 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



Certified that the above modification 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 worlds not applicable.