(To be retained by the Employer for future reference)

8 9 : ; < = > ? @ : : A B C D ? E F G : H I J K H G A L M 9 : < : N O P Q R S C T D T U D T = 9 V W X Y Q Z [

8 9 : ; < = > ? @ : : A B C : H A F ? H L M 9 : < : N O P P Q S C T D T U D T = 9 V R X [

       
      
           
                  
        
     
               

  !   
   "
    
       
                  #

 %  &   ' ( ) * + ( , ' * ) *  - .  ) + , / ) - ( .  0

1) NAME (TITLE)
MR . MS. MRS.
(PLEASE TICK)

2) DATE OF BIRTH D D M M Y Y Y Y

3) FATHER S/ 1

MR .
HUSBAND S NAME 1

4) RELATIONSHIP IN RESPECT OF (3) ABOVE FATHER HUSBAND

(PLEASE TICK)

5) GENDER MALE FEMALE TRANSGENDER

(PLEASE TICK)

6) MOBILE NUMBER
(IF ANY)

7) EMAIL ID (IF ANY)

8) WHETHER EARLIER A MEMBER OF THE EMPLOYEES PROVIDENT FUND SCHEME, 1952 ? 1

(PLEASE TICK)
7   . (

9) WHETHER EARLIER A MEMBER OF THE EMPLOYEES PENSION SCHEME, 1995? 1

(PLEASE TICK)
7   . (

$ 3 $

- 2    
   
 
 
 
2 0 4 0  
               
  2           
     
         

$
 5    !
   4 0 6

Page of

 & #    
     
         

10) THE DETAILS OF THE UNIVERSAL ACCOUNT NUMBER (UAN) OR PREVIOUS PF MEMBER ID:
, & .

OR
   
    ]      -  ^ _ ` a b c d b e _ f g g a h _ d b e _ i j k l m n a j o p _ c k q r i s k _ c j a b c t h h b u c k v u p m _ w

11) DATE OF EXIT FOR PREVIOUS D D M M Y Y Y Y

MEMBER ID (DD/MM/YYYY)

12) (A) IF SCHEME CERTIFICATE ISSUED FOR PREVIOUS EMPLOYMENT, THEN SCHEME CERTIFICATE NUMBER:___________
(B) IF PENSION PAYMENT ORDER (PPO) ISSUED FOR PREVIOUS EMPLOYMENT, THEN PPO NUMBER:______________
x # (          

13) INTERNATIONAL WORKER YES NO

(PLEASE TICK)
$ $ $ $
 y  y  y  y
- 2        
0  
                          0   0 4  0 6

13(A) COUNTRY OF ORIGIN (Please Tick)

INDIA OTHER THAN INDIA (IF YES, PLEASE
MENTION NAME OF THE COUNTRY)

13(B) PASSPORT NUMBER ______________________________

13(C) PASSPORT VALID FROM

D D M M Y Y Y Y

To D D M M Y Y Y Y

14) EDUCATIONAL NON- SENIOR POST TECHNICAL/

ILLITERATE MATRIC GRADUATE DOCTOR
QUALIFICATION MATRIC SECONDARY GRADUATE PROFESSIONAL
(PLEASE TICK)

15) MARITAL STATUS MARRIED UNMARRIED WIDOW/ WIDOWER DIVORCEE

(PLEASE TICK)

16) SPECIALLY ABLED YES NO IF YES, TICK THE CATEGORY

(PLEASE TICK) LOCOMOTIVE VISUAL HEARING

Page \ of

17) KYC DETAILS KYC DOCUMENT TYPE z
NAME AS ON KYC DOCUMENT NUMBER REMARKS, IF ANY
BANK ACCOUNT-1 IFSC CODE*
NPR/AADHAAR
PERMANENT ACCOUNT
NUMBER (PAN)
PASSPORT EXPIRY DATE
DRIVING LICENCE EXPIRY DATE
ELECTION CARD
RATION CARD
ESIC CARD
$

* ( :
] { | } { ~   } .
  x    &  
   . , ] x  +  
     -   / 
  0       
 #

YOU
ARE HOWEVER ADVISED TO PROVIDE ALL KYC DOCUMENTS AVAILABLE WITH YOU IN ADDITION TO MANDATORY KYCS TO
AVAIL BETTER SERVICES. MUST BE ATTACHED WITH THIS FORM.
   2 &         


  
2    
      

/ # ,          6

& # -     2            2
   
      
       
      
2   
             2 #

,
  !   
x # -                   
2              "
    

0 -               
        
2  , & . "    
           #

0 )       
                  2
      2  
2 2                    2          2 


      
    
              
  
           #  # &  
   # )        2   
     
    

  2        2   7 /          
       
     
            2          

   
                     /    2     0 #

- - - 0 -            -         ] 
   
 2
    
   , & .            
    #

    6

     6        
2 ]     

; 8 ; L ; 8 C ;

A. THE MEMBER HAS JOINED ON AND HAS BEEN ALLOTTED PF MEMBER ID

B. IN CASE THE PERSON WAS EARLIER NOT A MEMBER OF EPF SCHEME, 1952 AND EPS, 1995: $

THE UAN ALLOTTED FOR THE MEMBER IS


    
    
2 , & . 0

      )      &   
     (  
 6

THE KYC DETAILS OF THE ABOVE MEMBER IN THE UAN DATABASE
HAVE NOT BEEN UPLOADED

HAVE BEEN UPLOADED BUT NOT APPROVED

HAVE BEEN UPLOADED AND APPROVED WITH DSC

C. IN CASE THE PERSON WAS EARLIER A MEMBER OF EPF SCHEME, 1952 AND EPS, 1995:
THE ABOVE MEMBER ID OF THE MEMBER AS MENTIONED IN (A) ABOVE HAS BEEN TAGGED WITH HIS/HER UAN/PREVIOUS
MEMBER ID AS DECLARED BY MEMBER.       )      &   
     (  
 6

THE KYC DETAILS OF THE ABOVE MEMBER IN THE UAN DATABASE HAVE BEEN APPROVED WITH DIGITAL

SIGNATURE CERTIFICATE AND TRANSFER REQUEST HAS BEEN GENERATED ON PORTAL.

AS THE DSC OF ESTABLISHMENT ARE NOT REGISTERED WITH EPFO, THE MEMBER HAS BEEN INFORMED TO FILE

PHYSICAL CLAIM (FORM-13) FOR TRANSFER OF FUNDS FROM HIS PREVIOUS ESTABLISHMENT.

    6        
2    
        
2            

Page
of