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 mine).
I……………………………….(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……….Number………dated………shall stand modified in the following manner:
(Here give details of the modifications intended).
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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 address.
Village ………………..……Thana…………………..…….Sub-division……….…..Post Office………District…….State……
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Place…….. Signature/thumb impression
Date…….. of the employed person.
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Declaration by witness
Modification of nomination signed/thumb impression before me.
Name in full and full address Signature of witnesses
1.
2.
1.
2.
Place………
Date………
Certificate by the employer
Certified that the above modifications have been recorded and entered into in 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………….
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Acknowledgment by the employed person
Received the duplicate copy of the notice for modifications in Form III filed by me on duly certified by the employer.
Signature of the employed person.
Place………
Date………
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NOTE: Strike out the words not applicable.
