FORM III
[See sub-rule (6) of rule 3]
Modification of nomination

To
(Give here name and address of employer together with name and full address of the establishment).
..........................................................................................................
(name in full here)
whose particulars are given below hereby give notice that the nomination filed by me on and recorded under your reference number (date) shall stand modified in the following manner:-
(here give details of the modifications intended)
Statement
1. Name of the employed person in full:
2. Sex
3. Religion:
4. Whether unmarried/married/widow/widower:
5. Department/Branch/Section where employed
6. Post held with ticket number of serial number, if any:
7. Date of appointment:
8. Present address:
9. Permanent address:
Village………………..Thana………. Sub-Division………… Post Office……… District ……….. State…………..
Place……………
Date…………..
Signature/thumb-impression
of the employed person
Declaration by witnesses.
Modification nomination signed/thumb-impressioned before me.
Signature of witnesses
Name in full and address
1                                                                      1
2                                                                      2                     
Place………..
Date……….
(Certificate by the employer)
Certified that the particulars of the above nomination have been verified and recorded in the register of nominations in Form IV at Serial Number………………………………………….
Signature of the employer/
Officer authorised.
Date ………….
Place……………
Designation
Name and address of the
establishment or rubber stamp thereof.
Acknowledgment of the employed person
Received the duplicate copy of the nomination in Form I filled by me…… and duly certified by the employer.
Place…………..                                                  Signature of the employed person
Date………………..
Note- Strike out the words not applicable