Name of industrial establishment _____________________________________
Group/ section / shop / deptt. _________________________________________
I nominate ______________ (workmens representative eligible for election) as a candidate for election to the Works Committee. He is eligible as a voter in the constituency for which he is nominated.
Date __________________ Signature of proposer ___________
I agree to the proposed nomination.
Signature of candidate _____
Attested by :
(To be signed by any two voters belonging to the electoral constituency)