Declaration Form (Tobe retained by the Employer for future reference) Employees’ Provident Fund Organization ‘THe EMPLOYEES’ PROVIDENT FUNDS SCHEME, 1952 (PARAGRAPH-348 57) & ‘THE ENPLOYEES' PENSION SCHEME, 1995 (PARAGRAPH-24) DECLARATION BY A PERSON TAKING UP ENPLOYNENTIN AN EST ICH EW E OvEES! PENS 5) S APPLLU (PLEASE GO THROUGH THE INSTRUCTIONS) 1) Naw (Tine) Wor] s [wes ][PIAIAIN IT) ik |R Tease TK) HI @ = z > SB = o 2) Dare of Bar A 3) Fannie re Huseano's Nave * 4) ano? aero" (3) | Tee) e. 5) =. gs ope | 4/2 lo lz [4 [6 [o [3 |a [2 Dewi |p |p — ! S [7 fox Ip 5 | Ie- x K jo] U0 [> ls lo lo b> 3 |® 8) Werner cARULER 1 HERIER OF THE EMPLOYEES PROVIDENT FUND SCHEME, 7 (Puease TicK) ves 7 NO} 9) WhieTHER EARLIER A MEMBER OF THE EnLoveEs’ PewsiON ScHENE, 19957 (Puease Tien) ves 7 wo | TF RESPONSE TO ANY OR BOTH OF (8) & (9) ABOVE IS VES, THEN MANDATORILY FILL UP THE PREVIOUS EMPLOYMENT DETAILS aT (10,1181): Page 10 3‘A. Previous EwpLoyMent DeTalts 110) we DETALS OF THE UNIVERSAL AccOUNT NuMBER (UN) oR PREVIUS PF MEMBER 1D: vw [1tfTo]o]i fo [> [i ][2 [6 [é or Privous PF Mewsen '0 [REGION Cobe [OFFICE Cook | FsTABUSAMENTID | ExreNSON | AccOUNT NUMBER 11) one or Extrorerewous [0 [Oo [M|[M]Y)Y¥ ]¥|¥ Meweee 1D (DD/MM/YYYY) 12) (A) LF ScueNe cenviftCATE ISSUED FOR PREVIOUS EMPLOYMENT, THEN SC-EVE C22TIFICATE WB (6) IF eewstow parwent oRoER (PPO) ISSUED FOR FREN US EMPLOYNENT, THEN PPO NWB: 1B. oTHieR DeTms 13) nreruarionat WorrER se 7 ches) ES 1 rue ncecy 10 (13) ABOVE 1S VES, THENENTER THE OETALLS IV 43(A), 13(0) &13(C): 13(s) CounTRY OF ORIN (Please Tie) Tw ‘OTHER THAN SIA sMeatyon sass OF THE CO.NVT2Y) 13() Pssrowr nuns 5 344 35 113(c) PasspoRT vali> =30M Dye YY ]¥ aah | oft (= To foyo|" YiYvyY 1 2}o [2 [2 14) E> cA. SEMOR me) POT TECRTCALT QavFicanoy scconoay | PTE | Geynuare | POT | paoressionat (P2082 1e¢) a 15) Mata. STATIS TASS] wat | Wiaow/woower | Dwvorcee (P2=TIC) t 16)S%08.¥ 8D yw) [- Tr YES, TH THE CATEGORY (PLEASE TION) a Locoworve | visuat Heaaine Page 2 0f 3Puan! KALEHNA BADIPAT) 17) Kve permis [RYE Docume Tae] | Nae AS ON RYC DOCINET ‘una Renae. mT] Baw Account-1* -LISTATE BANK of wnotA| 2012 53135 43 TNPRAnOTANR DB PHANI RRISHNA D316 DDH @IDO PERMANENT RECOUNT reer T Nuec (PAN) 5 ANI KRISHNA PASSPORT — Ajeet aoHege aaa K BS3F435 Driving uence ELECTION CARO T ap [Raion CaR> | ESIC CHAD * Mandatory Field (WouE; Bawx Accouny NUMBER (10s wits IPSC CODE) is \wVoaTORY. YOU ARE HOWEVER ADVISED TO PROMDE ALL KYC DOCUMENTS AVAL_A2.2 WIT-4¥011¥ ADDITION TO MANDATORY KYCS TO AVAIL BETTER SERUCES. SELF-ATTESTED PHOTOCOPIES OF THE DOXUNIEVTS MST 3= ATTAC-ED WITH THIS FORK (CL UNDERTAKING! [AL I CERTIFY THAT ALL THE INFORMATION GIVE ABOVE IS TRUE TO THE BEST OF UV KNOWLEDGE AND BELIEF. B. INCASE, EARLIER A MEMBER OF EPF SCHEV, 1952 avD/0n EPS, 1995, (0) | HAVE ENSURED THE CORRECTNESS OF SW UAN/ PREVIOUS PF ME\BER 10, (i) THIS MAY ALSO BE TREATED AS MTY REQUEST FOR TRANSFER OF FUNDS AND SERVICE DETAILS IF APPLICABLE FROM THE PREVIOUS ACCOUNT AS DECLAMED ABOVE TO THE PRESENT PLF. ACCOUNT. (TVE TRANSTER WOULD BE POSSIBLE ONLY IF THE IDENTIFIED KYC DETAILS APPROVED BY PREVIOUS EMPLOYER HAS BEEN VERIFIED RY PRESENT EMPLOYER USING HIS DIGITAL SIGNATURE CERTIFICATE). (UU) atm awaze THAT CAN SUBMIT MY NOMINATION FOR THROUGH UAN BASED MENBER PORTAL. fot 2/16) Grows) SIGNATURE OF MEMBER DECLARATION BY PRESENT EMPLOYER A Te MAS JOINED OM .ssssscneem AND HAS BEEN ALLOTIED PF EMBER 10 Bo Nose Cr EPF ScHene, 1952 ano EPS, 1995 + (Post ALLOTMEVTOF VAN) T-= UAN &oTTED FoR THe wesc is + PLease THex THE APPROPRIATE OPTION? ‘THE KYC 951A SO T-€ #S0¥= MENGE IW THE UAN onraBase JP.RDD 3. NOT APPROVED N-P.QADED ANE APPROVED WITH DSC ER OF EPF SCHEME, 1952 AND EPS, 1995: MBER AS MENTIONED In (A) ABOVE HAS BEEN TAGGED WITH RIS/MER UAN/PRE MOUS 2D 66 DCAD 20 TIO THE APPROPRIATE OPTION: ~ ‘Toe KYC DeTALS OF THE ABOVE MEMBER IN THE UAN DATABASE HAVE BEEN APRROVED ATH DIGITAL SIGNATURE CERTIFICATE AND TRANSFER REQUEST HAS BEEN GENERATED ON PORTAL DAS THE DSC oF ESTABLISHMENT ARE NOT REGISTERED WITH EPFO, THE MEMIER HAS BEEN 1HFORMED TO FILE PPAYSICAL CLAM (FORM-1) FOR TRANSFER OF FUNDS FROM HIS PREVIOUS ESTABLISHMENT + PLEAS Dare: SIGWATURE OF EMPLOYER WITH SEAL OF ESTABLISHMENT Page 30r8