Nomination form to be filled by Agent on appointment

Nomination form to be filled by Agent on appointment

Original / Duplicate / Triplicate

I ................................................................................. the Agent under this agreement hereby nominate the persons(s) mentioned below, who shall, on my death, become entitled to any amount due and payable to me by way of commission in terms of this agreement, to the exclusion of all other persons.

Sl.No. (1)	Name of the Nominee(s) (2)	Full Address (3)	Date of birth of nominee, if minor (4)

2. As the nominee(s) at serial No.(2) above, is/are minor(s) I appoint the following person(s) to receive the aforesaid amount in the event of my death during the minority of the nominee(s)

Name of nominee

Name and address of persons appointed

...................................................

................................................................

..................................................

................................................................

...................................................

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Place:

Signature:

Date:

Name of Agent in full
C.A. No. and Address:

Witness:

1. Signature with date
Name & full Address.

2. Signature with date
Name & full Address.

(One to be given to the Post Office, another to the Agent and the third copy to be retained in the Office.)