FORM No. 36

(Prescribed under Rule 119)

 Nomination for payment of wages in lieu of the quantum of leave to which he was entitled in the event of death of worker.

 

I hereby nominate Shri ………………………………………………………
who is my …………………………………………………………… and resides at………………………………………………………………..as to receive
the amount of the balance of my wages in lieu of the quantium of leave not availed of, in the event of my death before resuming works.

Dated this ………………………………………… Day of …………………at ……………….

 

Witness

1.       Signature               :

          Name                    :

          Address                :

 

2.       Signature               :

          Name                    :

          Address                :

 

Signature or left thumb impression of the worker

Particulars of worker such as serial number in the register or adult/ child workers, section or department, etc.

 

Date :