FORM A

Nomination form for payment of gratuity under section 5 of the Working Journalists (Conditions of service) and Miscellaneous Provisions Act, 1955
[See rule 5(l)]

1. Name (in block letters)………………………
 Surname (if any)………………………………
2. Sex……………………………………………
3. Religion………………………………………
4. Occupation……………………………………
5. Father's name…………………………………
6. Husband's name………………………………..
 (for married women only)
7. Marital Status…………………………………..
 whether bachelor, spinster, married, widow or widower
8. Date of birth……………. Day………………. Month ………….Year……….
9. Permanent address………………………………………….
Village…………. Thana ………….District………….. State……………….
I hereby nominate the person/s mentioned below to receive the amount of gratuity ding to my credit, in the event of my death before that amount has become payable, or ing become payable has not been paid and direct that the said amount shall be distributed one the said persons in the manner shown below against their names

Name and address of the nominees	Nominee’s relationship with the working journalist	Age of nominee	Amount of share of gratuity to be paid to each nominee	Contingencies on the happening of which the nomination shall become invalid
1	2	3	4	5

             
Date............... Signature of the working journalist
Certified that above declaration has been signed by ……………………employed in
…………………………………(the name of the newspaper establishment to be given
Due me after
Before me after he has read the entries/ the entries have been read over to him by me.
Dated……………..     Signature of a responsible officer of the Newspaper establishment
Signature of witness…………. (1) Designation……………………
Dated…………………….
Signature of witness…………….         (2) Name and address of the newspaper
Establishment……………………
Dated………………