| Serial No. | Name (s) of the nominee(s) | Full Address(es) | Date of birth of nominee in case of minor |
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As the nominee(s) at Serial
No.(s)__________ specified above is /are minor(s) I appoint
Shri/Smt/Kumari__________________________________________________________________
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| Signature of witness: Name and address : |
| Date: |
Signature or
Thumb impression |
| Signature of witness: Name and address: Date: |
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| ____________________________________________________________________________ |
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| FOR THE USE OF ACCOUNTS OFFICE |
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| The above nomination has been registered on __________ and entry made in the Pass Book.
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| Date: | Signature of Accounts Officer |
| * Delete if not applicable |
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