Attached is the format that needs to be filled. On the front page, the Name & Address of the Establishment, Name of the Employee in full, as well as the Nominee's details need to be furnished. Clause no. 5 need not be filled. The number of nominations depends and can be either spouse, father, and/or mother with the proportions shared accordingly.
On page 2, the details of the employee need to be furnished along with the signature. Additionally, the details and signature of the witnesses are required.
On page 3, only the acknowledgment needs to be signed by the employee. The certificate by the employer needs to be filled out by the organization.
Hope this resolves your query.
Regards