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Gopal Rai
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Result
Citizen Feedback Form
Form H  Modification of nomination

 
[See sub-rule (4) of rule 6]
 
Modification of nomination
 
To…………………………
 
[Give here name or description of the establishment with full address]
I, Shri/Shrimati/Kumari ………………… [Name in full here] whose particulars are given in the statement below, hereby give notice that the nomination filed by me on [date] and recorded under your reference No ………… dated ……………… shall stand modified in the following manner:
[Here give details of the modifications intended]

Statement



   
1.
Name of employee in full. .....................................................
2.
Sex......................................................
3.
Religion. .....................................................
4.
Whether unmarried/married/widow/widower. .....................................................
5.
Department/Branch/Section where employed. .....................................................
6.
Post held with Ticket or Serial No., if any. .....................................................
7.
Date of appointment. .....................................................
8.
Address in full. .....................................................
Place
............................. Signature/Thumb impression
 
of the employee
Date
.............................
 
Declaration by witnesses
 
Modification of nomination signed/thumb impressed before me.
Name in full and full Signature of witnesses.
address of witnesses.  
1. ............................. 1. .............................
2. ............................. 2. .............................
Place .............................  
Date .............................  
Certificate by the employer
Certified that the above modification have been recorded.
Employer's reference No., if any. Signature of the employer/
officer authorised
  Designation
Date   Name and address of the
establishment or rubber stamp thereof.

Acknowledgement by the employee


Received the duplicate copy of the notice for modification in Form ‘H’ filed by me on ……
…………… duly certified by the employer.
Date
Signature of the employee
Note: Strike uot the words not applicable.
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Last Updated : 23 Mar,2014
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