Form A – THE WORKING JOURNALISTS (CONDITIONS OF SERVICE) AND MISCELLANEOUS PROVISIONS RULES,1957

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.Fathers name

6.Husbands 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 in 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

Nominees 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

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MyNation

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