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Bare acts > Working Journalists (Conditions of Service) and Miscellaneous Provisions Rules, 1957 > Form A
 
   


 

FORM A


Nomination form for payment of gratuity under Sec. 5 of the Working Journalists
(Conditions of Service) and Miscellaneous Provisions Act, 1955.
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 …….
9. Permanent address :
Village…………Thana…………District……….State…………..
I hereby nominate the person(s) mentioned below to receive the amount of gratuity standing
to my credit, in the event of my death before that amount has become payable, or having
become payable has not been paid and direct that the said amount shall be distributed
among the said persons in the manner shown below against their names:

Name and address of Nominee’s relationship Age of Amount of share Contingencies on the
the nominee or with the working nominee of gratuity to be happening of which
nominees journalist paid to each the nomination shall
nominee become invalid.
1 2 3 4 5
Dated ……………… Signature of the working journalist
Certified that the above declaration has been signed by
………………. Employed in ………………….( the name of the newspaper establishment to
be given) 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
Dated: newspaper establishment….
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