Form of nomination

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..... .. 5. Husband s name . . [for married woman only] 6. Marital status . .. [whether unmarried, married, widow or widower] 7. Date of birth: Day Month .. Year . 8. Permanent address: Village Thana .. Taluk/Sub-Division Post Officer District .. State .....

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..... 1 2 3 4 *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) is /are dependent upon me. Dated this da .....

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