FORM OF NOMINATION OF BENEFICIARIES

Name:

___________________________________________________

Designation:

___________________________________________________

Department/Section: ___________________________________________________
I hereby nominate the person/persons mentioned in part-I/Part-II for the grant of pension,
Benevolent Funds, Group Insurance or any other gratuities to be paid as per rules/laws/Acts by the
Government of the Punjab in the event of my death.
PART-I (For wife/husband only)
Sr.
No.

Name of
nominee/
nominees

Relationship

Age

Proportion of
the share to
be paid

If, the nominee is

minor, name of the
person/persons to
whom payment is to
made on his behalf

PART-II (For family members other than wife/husband or for other relatives)
Certified that the member/members of my family/ other relatives (other than family
members) mentioned in following table is/are wholly dependent upon me.
If, the nominee is
Name of
Proportion of
minor, name of the
Sr.
nominee/
Relationship
Age
the share to
person/persons to
No.
nominees
be paid
whom payment is to
made on his behalf

All the earlier nomination made by me may kindly be treated as cancelled.

Signature:

_________________
OR

Thumb Impression:
(of Employee)

_________________

Date:

_____/_____/_____

CHECKED/VERIFIED/ATTESTED BY
Signature:

_________________

Designation/Stamp: _________________
Date:

Jerjees Haider Shah

_____/_____/_____