FORM FOR NOMINATION

Bank of Baroda Gratuity Fund

EC No. : . . . . . . . . . . ALPHA : . . . . . . . . . .

1. Name of employee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Surname . . . . . . . . . . . . . .

(In Block letters)
2. Sex . . . . . . .
3. Religion . . . . . . .
4. Father's Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5. Husband's Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (for married woman only)
6. Marital Status . . . . . . . . . . . . . . . . (whether unmarried, married, widow or widower)
7. Date of Birth: Day . . . . . . . . . . . Months . . . . . . . . . . . Year . . . . . . . . . . .
8.Permanent A ddress : . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Village . . . . . . . . . . . . . . . . . . Thana. . . . . . . . . . . . . . . . . . Taluka/Sub-Division . . . . . . . . . . . .
Post Office . . . . . . . . . . . . . District . . . . . . . . . . . . . State . . . . . . . . . . . . .
I hereby nominate the person(s) mentioned below to receive the amount of Gratuity Fund in the
event of my death before the amount become payable, or having become payable, has not been
paid, and direct that the said amount shall be distributed among the said person(s) in the
manner shown against their names:

Nominee's Birth +Amount or share of

relationship Ageofof Gratuity to be paid to
Date
with the each nominee
Name of nominee/s Address of nominee/s Nominee
nominee
employee & Age
1

4
5

1. Certified that I have no family and should I acquire a family hereafter, the above nomination
should be deemed as cancelled.
2. Certified that my father / mother / sister(s) / minor brother(s) mentioned above is / are
Solely dependent upon me.
Dated this . . . . . . . . . . . . . day of . . . . . 20 . . . at . . . . . . . . . . . . .

Two witness to Signature :

1. . . . . . . . . . . . . . ...................
2. . . . . . . . . . . . . . (Signature of employee)

Certified that the above declaration has been signed by Shri / Smt. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
he/she has read the entries before me after + the entries have been read over to him / her by me.

Full Address of the Branch For BANK OF BARODA

Seal of the branch

Date: . . . . . . . . . . . . . . . . . . . Signature of Branch Manager
# Delete the inapplicable words
+ This column should be filled in so as to cover the whole of the amount that may stand to the
credit of the employee in the Provident Fund in the event of his/her death.
Important : Form to be routed through Regional Office