To
[Give here name or description of the establishment with full address]
I, Shri/ShrimatilKumari [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 the employee in full.
2. Sex.
3. Religion.
4. Whether unmarried/married/widow/widower.
5. Department/Branch/Section where employed.
6. Post held with Ticket No. or Serial No., if any.
7. Date of appointment.
8. Address in full.
Place Signature/Thumb impression
Date of the employee
Declaration by witnesses
Modification of nomination signed/thumb impressed before me.
Name in full and full Signature of witnesses.
address of witnesses.
I. L
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
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 out the words not applicable.
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