FORM I
[See sub-rule (1) of rule 3]
Nomination

To
(Give here name and address of employer together with name and full address of the mine)
I…………………………      
(name in full here)
whose particulars are given In the statement below hereby nominate the person mentioned below to receive all amounts Payable to me as wages If such amounts could not or cannot be paid on account of my death before the payment or on account of my whereabouts not being known.
2. I hereby certify that the person nominated by me is a member of my family within the meaning of Cl. (d) of rule 2 of the Payment of Undisbursed Wages (Mines) Rules, 1989.
3. I hereby declare that I have no family within the meaning of Cl. (d) of rule 2 of thesaid rules and should I acquire a family hereafter, the above nomination shall be void and in that event I shall make a fresh nomination in Form II.
4.         (a) My father/mother/parents is/are not dependent upon me.
(b) My husband's father/mother/parents is/are not dependent on my husband.

Nominee
Name and address the nominee	Nomiee’s relationship with the employed person	Age of nominee
1	2	3

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 or serial number, if any.
7. Date of appointment:
8. Present address
9. Permanent :
Village…….. Thana…….. Sub-division……….Post Office……..District........State
Place…….                                                Signature/thumb-impression
                                                                 of the employed person
Date…….                                                 Declaration by witness
Nomination signed/thumb-impression before me
Name in full and full address
Signature of witnesses
1 .                                                                 1 .                                  
2.                                                                  2.
Place……….
Date…..          
Certificate by 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
Designation
Name and address of
the mine or rubber stamp
thereof.
Place………
Date……….
___________________________________________________________________
Acknowledgment of 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 and paragraphs not applicable.
                                                                        __________