NOMINATION FORM 1. The agent under the agreement hereby nominate below, who shall on my death become entitled to any amount due and payable to me way of commission in terms of this agreement to the exclusion of all other persons: S.NO. NAME OF THE NOMINEE FULL ADDRESS 2. As the nominee(s) at Sr.No (s) above, is are minor(s), I appoint the following person to receive the aforesaid amount in the event of my death during the minority of the nominee(s). Name of Nominee: Name and address of person appointed _________________________________ __________________________________ Place___________________ Dated___________________ Signature (Name of the agent in full) Witness: C.A.No__________________ Address___________________ 1. Signature with date Name &Full Address 2 Signature with date Name& Full Address Nominee Accepted
