| 1. |
Name of applicant nominee |
......................................... |
| 2. |
Address of full of the applicant nominee |
......................................... |
| 3. |
Marital status of the applicant nomineeUnmarried/Married/Widow/Widower
|
......................................... |
| 4. |
Name of the employee in full |
......................................... |
| 5. |
Marital status of the employee |
......................................... |
| 6. |
Relationship of the nominee with the employee |
......................................... |
| 7. |
Date of initial appointment of the employee |
......................................... |
| 8. |
Date of termination of service of the employee |
......................................... |
| 9. |
Cause of termination of service of the employee |
......................................... |
| 10. |
Office, where last employed |
......................................... |
| 11. |
Pest last held |
......................................... |
| 12. |
Total period of service of the employee |
.........................................(Years) (Months)(Days)
|
| 13. |
Date of death and evidence/witness as proof of death of theemployee
|
......................................... |
| 14. |
Total wages last drawn by the employee |
......................................... |
| 15. |
Reference No of recorded nomination, if available |
......................................... |
| 16. |
Total gratuity payable to the employee |
......................................... |
| 17. |
Share of gratuity claimed |
......................................... |