XYZ & CO. EPF No.

MH / THA / 123456 /
ESIC No. 31 000 12345 000 0123
ADDRESS

D. O. J Date of Birth

SR. EPF
ESIC No. Name of the Employee Father's / Husband Name Maritial Status Sex Nationality Religion
No. No. DD MM YYYY DD MM YYYY

[1] [2] [3] [4] [5] [6] [7] [8] [9] [10] [11] [12] [13] [14] [15]

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 Nature of Work /
Branch Department Present Address City District State Pincode
Designation

[16] [17] [18] [19] [20] [21] [22] [23]

Permanent Address City Post Office Village Sub division Thana District State Pincode

[24] [25] [26] [27] [28] [29] [30] [31] [32]

 ESIC - 1'st Nominee Family 1

Email ID Local Office Dispensary

Name Relationshp Address Name Date of Birth Relationship

[33] [34] [35] [36] [37] [38] [39] [40] [41]

Family 1 Family 2
Whether Whether
Percent of Percent of
residing residing
Town State Address Amount Name Date of Birth Relationship Town State Address Amount
with with
Share Share
him/her him/her
[42] [43] [44] [45] [46] [47] [48] [49] [50] [51] [52] [53] [54]
 Family 3 Family 4
Whether Whether
Percent of
residing residing
Name Date of Birth Relationship Town State Address Amount Name Date of Birth Relationship
with with
Share
him/her him/her
[55] [56] [57] [58] [59] [60] [61] [62] [63] [64] [65] [66]
Family 4 Family 5
Whether
Percent of Percent of
residing
Town State Address Amount Name Date of Birth Relationship Town State Address Amount
with
Share Share
him/her
[67] [68] [69] [70] [71] [72] [73] [74] [75] [76] [77] [78]
 Family 6 WITNESS SHOWN UNDER GRATUITY
Whether
Percent of
residing
Name Date of Birth Relationship Town State Address Amount Name of Witness 1 Address of Witness 1
with
Share
him/her
[79] [80] [81] [82] [83] [84] [85] [86] [87] [88]
ESS SHOWN UNDER GRATUITY

Mobile No. Personal Contact No. at House Bank Account No. Type of Account Name of Bank
Name of Witness 2 Address of Witness 2

[89] [90] [91] [92] [93] [94] [95]

 MICR Code of Bank / IFSC Code of the Bank /
Name of the Branch Any Type of Disability Previous Employer
Branch Branch

[96] [97] [98] [99] [100]

 FORM --- 2 (REVISED) 1 Please en
NOMINATION AND DECLARATION FORM whom you
FOR UNEXEMPTED / EXEMPTED ESTABLISHMENTS the form.
Nehal:
Declaration and Nomination Form under the Employees' Provident Funds and Employees' Pension Scheme.
(Paragraph 33 & 61(1) of the Employees' Provident Fund Scheme, 1952 & Paragraph 18 of the Employees' Pension Scheme, 1995)
Date of Joinning :
1. Name of Employee :
2. Fathers / Husband's Name :
3. Date of Birth : 5. Maritial Status :
4. Sex : 6. Account No. : MH / THA / 123456 /
7. Present Address : 8. Permenant Address :

Pincode No. Pincode No.

PART - A (EPF)
I hereby nominate the person(s)/cancel the nomination made by me previously and nominate the person(s), mentioned below to receive the amount
standing to my credit in the Employees' Provident Fund, in the event of my death.
Name of the Nominee / Nominees. Address Nominee's Date of Birth Total amt. or If the Nominee is a minor,
Relationship share of name & relationship &
with the accumulatio address of the guardian
member ns in who may receive the
Provident amount during the minority
Fund to be of nominee.
paid to each
nominee

1. * Certified that I have no family as defined in para2(g) of the Employees' Provident Fund Scheme, 1952 and should I acquire a family hereafter the
above nomination should be deemed as cancelled.
2. * Certified that my father/mother is/are dependent upon me.
* Strike out whichever is not applicable. Signature or thumb impression of the Subscriber
PART - B (EPS)
(Para 18)
Name & Address of the Family Member
Sr. No. Date og Birth Relationship with member
Name Address
1 0 0 12/30/1899 0

2 0 0 12/30/1899 0

3 0 0 12/30/1899 0
** Certified that I have no family, as defined in Para 2(vii) of Emplotees' Pension Scheme, 1995 and should I acquire a family here after I shall furnish
particulars thereon in the above form.
I hereby nominate the following person for receiving the monthly widow pension (admissible under para 16 2(a) (i) & (ii) in the event of my death without
leaving any eligible family member for receiving pension.
Name & Address of the Nominee
Date of Birth Relationship with the member
Name Address

** Strike out whichever is not applicable.

Date : 7/19/2023 (Signature or thumb impression of the subscriber)

CERTIFICATE BY EMPLOYER
Certified that the above declaration and nomination has been signed/thumb impression before me by SHRI/SMT./KUMARI
0 employed in my establishment after he/she has read the entires/entries
have been read over to him/her by me and got confirmed by him/her.
Place : SURAT Dated the : 7/19/2023

XYZ & CO. Signature of the Employer or Other

Authorised Officers of the Establishment

Designation
ADDRESS
Name & Address of the Factory/Establishment
and Rubber Stamp thereof.
Please enter Sl.No. for
whom you want to print
the form.
Nehal:
 EMPLOYEES STATE INSURANCE CORPORATION Ple
TEMPORARY IDENTITY CERTIFICATE 2 fo
Pr
ONLY FOR FORM FEEDING FOR ONLINE REGISTRATION THIS FORM IS NOT FOR TREATMENT
Insured Person
Insurance No.
Date of Registration 7/19/2023
YOUR REGISTRATION DETAILS

Employee Name: Type of Disability :

Name of Father / Husband Name Date of Birth:

Marital Status: Gender

Present Address: Permenant Address :

Dispensary / IMP : Local Office

Current Employer Details Previous Employer Details:
Employer's Code No. : 31 000 12345 000 0123 Employer's Code No. :
Sub Unit's Code No. Sub Unit's Code No.
Date of Appointment: Previous Insurance No. :

Name of the Employer : XYZ & CO. Name of the Employer :

Address of Employer : ADDRESS Address of Employer :

Family Details :
Whether Residing
Name Relationship with the Employee Date of Birth State District
with him

Nominee Details:
Name of Nominee Relationship with IP Percentage Address of Nominee
100%
Details of Bank :
Type of
Account No. Name of Bank Branch Micr Code of Bank IFSC Code No.
Account

Documents Uplodaed:
Please Verify the above particulars.
Please Notify Your Employer or in the Brnach Office Address Below Incase of any Information Found Incorrect.
To get permanent ID Card, employee is requested to visit the following branch office to get biometric & photo captured
by this date in the mentioned BRANCH Office: 0
Signature / LTI of Registered Employee / IP :

Mobile No.
Contact of Home
Please Enter Serial No.
for whom you want to
Print the Form Nehal:
 FORM - F 1 Please
[See sub-rule (1) of rule 6] whom
Nomination the for
Nehal:
To,

XYZ & CO.

ADDRESS
1 Shri. son/husband of
whose particulars are given in the statement below, hereby nominate the person(s) mentioned below to receive the fratuity payably
after my death as also the gratuity standing to my credit in the event of my death before that amount has become payable, or having
become payable has not been paid and direct that the said amount of gratuity shall be paid in proportion indicated against the name(s)
2 I Hereby certify that the person(s) mentioned is/are member(s) of my family within the meaning of clause(h) of section(2) of
The Payment of Gratuity Act, 1972.
3 I hereby declare that I have no family within the meaning of clause (h) of section (2) of the said Act.
4 (a) My father/mother/parents is/are not dependent on me.
(b) My husband's father/mother/parents is/are not dependent on my husband.
5 I have excluded my Husband from my family by a notice dated to the Controlling Authority in terms of the provision to clause(h) of
Section 2 of the said Act.
6 Nomination made herein invalidated my previous nomination.
Nominee(s)
Name & Address of the Nominee(s)
Proportion
Sr. Relationship with the Birth date or Age by which the
No Name of Nominee Address of Nominee employee of Nominee gratuity will
be shared

3
STATEMENT
1 Name of the Employee 2. Sex :
3 Father/Husband Name: 3. Maritial Status :
4 Religion : 5. Post held with Ticket or Serial No., if any. :
6 Department / Branch / Section
where employed. : [DD] [MM] [YYYY]
8 Date of Appointment :
10. Present Address 11. Permanent Address

Post Office Village

Sub-division Thana
District State
Place : Surat
Date : 7/19/2023 Signature / Thumb impression of Employee
Declaration by witnesses
Nomination signed/thumb impressed before me.
Name if Full & Full address of witnesses. Signature of witnesses
1
1
2
2
Certificate by the Employer
Certified that the particulars of the above nomination have been verified and recorded in this establishement.
Employer's Reference No., if any.
Date : 7/19/2023
Signature of the Employer / Officer Authorised
XYZ & CO.
Desig : PARTNER

ADDRESS Name and Address of the Establishment or rubber

stamp thereof
Acknowledgement by the Employee
Received the duplicate copy of nomination in Form 'F' filed by me and duly certified by the Employer.
Date : 7/19/2023 Signature of the Employee
Please enter Sl.No. for
whom you want to print
the form.
Nehal:
 Form No. 15 XYZ & CO.
(Prescribed under rule 88)
ADDRESS
Register of Adult Workers
Adolescent if any
Group of which worker belongs
certified as adults
Number of
Sr. Date of relay if Number &
Name Date of Birth Sex Residential Address Father's / Husband Name Number Remarks
No. Appointment Alphabet working date of
Nature of Work under
Assigned shifts Certificates
Section 68
of Fitness

1 0 0 0 0 0 0 0 0 0 0 0 N. A. N. A. N. A.

2 0 0 0 0 0 0 0 0 0 0 0 N. A. N. A. N. A.

3 0 0 0 0 0 0 0 0 0 0 0 N. A. N. A. N. A.

4 0 0 0 0 0 0 0 0 0 0 0 N. A. N. A. N. A.

5 0 0 0 0 0 0 0 0 0 0 0 N. A. N. A. N. A.

6 0 0 0 0 0 0 0 0 0 0 0 N. A. N. A. N. A.

7 0 0 0 0 0 0 0 0 0 0 0 N. A. N. A. N. A.

8 0 0 0 0 0 0 0 0 0 0 0 N. A. N. A. N. A.

9 0 0 0 0 0 0 0 0 0 0 0 N. A. N. A. N. A.
 Form No. 15 XYZ & CO.
(Prescribed under rule 88)
ADDRESS
Register of Adult Workers
Adolescent if any
Group of which worker belongs
certified as adults
Number of
Sr. Date of relay if Number &
Name Date of Birth Sex Residential Address Father's / Husband Name Number Remarks
No. Appointment Alphabet working date of
Nature of Work under
Assigned shifts Certificates
Section 68
of Fitness

10 0 0 0 0 0 0 0 0 0 0 0 N. A. N. A. N. A.

11 0 0 0 0 0 0 0 0 0 0 0 N. A. N. A. N. A.

12 0 0 0 0 0 0 0 0 0 0 0 N. A. N. A. N. A.

13 0 0 0 0 0 0 0 0 0 0 0 N. A. N. A. N. A.

14 0 0 0 0 0 0 0 0 0 0 0 N. A. N. A. N. A.

15 0 0 0 0 0 0 0 0 0 0 0 N. A. N. A. N. A.

16 0 0 0 0 0 0 0 0 0 0 0 N. A. N. A. N. A.

17 0 0 0 0 0 0 0 0 0 0 0 N. A. N. A. N. A.

18 0 0 0 0 0 0 0 0 0 0 0 N. A. N. A. N. A.
 Form No. 15 XYZ & CO.
(Prescribed under rule 88)
ADDRESS
Register of Adult Workers
Adolescent if any
Group of which worker belongs
certified as adults
Number of
Sr. Date of relay if Number &
Name Date of Birth Sex Residential Address Father's / Husband Name Number Remarks
No. Appointment Alphabet working date of
Nature of Work under
Assigned shifts Certificates
Section 68
of Fitness

19 0 0 0 0 0 0 0 0 0 0 0 N. A. N. A. N. A.

20 0 0 0 0 0 0 0 0 0 0 0 N. A. N. A. N. A.

21 0 0 0 0 0 0 0 0 0 0 0 N. A. N. A. N. A.

22 0 0 0 0 0 0 0 0 0 0 0 N. A. N. A. N. A.

23 0 0 0 0 0 0 0 0 0 0 0 N. A. N. A. N. A.

24 0 0 0 0 0 0 0 0 0 0 0 N. A. N. A. N. A.

25 0 0 0 0 0 0 0 0 0 0 0 N. A. N. A. N. A.

26 0 0 0 0 0 0 0 0 0 0 0 N. A. N. A. N. A.

27 0 0 0 0 0 0 0 0 0 0 0 N. A. N. A. N. A.
 Form No. 15 XYZ & CO.
(Prescribed under rule 88)
ADDRESS
Register of Adult Workers
Adolescent if any
Group of which worker belongs
certified as adults
Number of
Sr. Date of relay if Number &
Name Date of Birth Sex Residential Address Father's / Husband Name Number Remarks
No. Appointment Alphabet working date of
Nature of Work under
Assigned shifts Certificates
Section 68
of Fitness

28 0 0 0 0 0 0 0 0 0 0 0 N. A. N. A. N. A.

29 0 0 0 0 0 0 0 0 0 0 0 N. A. N. A. N. A.

30 0 0 0 0 0 0 0 0 0 0 0 N. A. N. A. N. A.

31 0 0 0 0 0 0 0 0 0 0 0 N. A. N. A. N. A.

32 0 0 0 0 0 0 0 0 0 0 0 N. A. N. A. N. A.

33 0 0 0 0 0 0 0 0 0 0 0 N. A. N. A. N. A.

34 0 0 0 0 0 0 0 0 0 0 0 N. A. N. A. N. A.

35 0 0 0 0 0 0 0 0 0 0 0 N. A. N. A. N. A.

36 0 0 0 0 0 0 0 0 0 0 0 N. A. N. A. N. A.
 Form No. 15 XYZ & CO.
(Prescribed under rule 88)
ADDRESS
Register of Adult Workers
Adolescent if any
Group of which worker belongs
certified as adults
Number of
Sr. Date of relay if Number &
Name Date of Birth Sex Residential Address Father's / Husband Name Number Remarks
No. Appointment Alphabet working date of
Nature of Work under
Assigned shifts Certificates
Section 68
of Fitness

37 0 0 0 0 0 0 0 0 0 0 0 N. A. N. A. N. A.

38 0 0 0 0 0 0 0 0 0 0 0 N. A. N. A. N. A.

39 0 0 0 0 0 0 0 0 0 0 0 N. A. N. A. N. A.

40 0 0 0 0 0 0 0 0 0 0 0 N. A. N. A. N. A.

41 0 0 0 0 0 0 0 0 0 0 0 N. A. N. A. N. A.

42 0 0 0 0 0 0 0 0 0 0 0 N. A. N. A. N. A.

43 0 0 0 0 0 0 0 0 0 0 0 N. A. N. A. N. A.

44 0 0 0 0 0 0 0 0 0 0 0 N. A. N. A. N. A.

45 0 0 0 0 0 0 0 0 0 0 0 N. A. N. A. N. A.
 Form No. 15 XYZ & CO.
(Prescribed under rule 88)
ADDRESS
Register of Adult Workers
Adolescent if any
Group of which worker belongs
certified as adults
Number of
Sr. Date of relay if Number &
Name Date of Birth Sex Residential Address Father's / Husband Name Number Remarks
No. Appointment Alphabet working date of
Nature of Work under
Assigned shifts Certificates
Section 68
of Fitness

46 0 0 0 0 0 0 0 0 0 0 0 N. A. N. A. N. A.

47 0 0 0 0 0 0 0 0 0 0 0 N. A. N. A. N. A.

48 0 0 0 0 0 0 0 0 0 0 0 N. A. N. A. N. A.

49 0 0 0 0 0 0 0 0 0 0 0 N. A. N. A. N. A.

50 0 0 0 0 0 0 0 0 0 0 0 N. A. N. A. N. A.

51 0 0 0 0 0 0 0 0 0 0 0 N. A. N. A. N. A.

52 0 0 0 0 0 0 0 0 0 0 0 N. A. N. A. N. A.

53 0 0 0 0 0 0 0 0 0 0 0 N. A. N. A. N. A.

54 0 0 0 0 0 0 0 0 0 0 0 N. A. N. A. N. A.
 Form No. 15 XYZ & CO.
(Prescribed under rule 88)
ADDRESS
Register of Adult Workers
Adolescent if any
Group of which worker belongs
certified as adults
Number of
Sr. Date of relay if Number &
Name Date of Birth Sex Residential Address Father's / Husband Name Number Remarks
No. Appointment Alphabet working date of
Nature of Work under
Assigned shifts Certificates
Section 68
of Fitness

55 0 0 0 0 0 0 0 0 0 0 0 N. A. N. A. N. A.

56 0 0 0 0 0 0 0 0 0 0 0 N. A. N. A. N. A.

57 0 0 0 0 0 0 0 0 0 0 0 N. A. N. A. N. A.

58 0 0 0 0 0 0 0 0 0 0 0 N. A. N. A. N. A.

59 0 0 0 0 0 0 0 0 0 0 0 N. A. N. A. N. A.

60 0 0 0 0 0 0 0 0 0 0 0 N. A. N. A. N. A.

61 0 0 0 0 0 0 0 0 0 0 0 N. A. N. A. N. A.

62 0 0 0 0 0 0 0 0 0 0 0 N. A. N. A. N. A.

63 0 0 0 0 0 0 0 0 0 0 0 N. A. N. A. N. A.
 Form No. 15 XYZ & CO.
(Prescribed under rule 88)
ADDRESS
Register of Adult Workers
Adolescent if any
Group of which worker belongs
certified as adults
Number of
Sr. Date of relay if Number &
Name Date of Birth Sex Residential Address Father's / Husband Name Number Remarks
No. Appointment Alphabet working date of
Nature of Work under
Assigned shifts Certificates
Section 68
of Fitness

64 0 0 0 0 0 0 0 0 0 0 0 N. A. N. A. N. A.

65 0 0 0 0 0 0 0 0 0 0 0 N. A. N. A. N. A.

66 0 0 0 0 0 0 0 0 0 0 0 N. A. N. A. N. A.

67 0 0 0 0 0 0 0 0 0 0 0 N. A. N. A. N. A.

68 0 0 0 0 0 0 0 0 0 0 0 N. A. N. A. N. A.

69 0 0 0 0 0 0 0 0 0 0 0 N. A. N. A. N. A.

70 0 0 0 0 0 0 0 0 0 0 0 N. A. N. A. N. A.

71 0 0 0 0 0 0 0 0 0 0 0 N. A. N. A. N. A.

72 0 0 0 0 0 0 0 0 0 0 0 N. A. N. A. N. A.
 Form No. 15 XYZ & CO.
(Prescribed under rule 88)
ADDRESS
Register of Adult Workers
Adolescent if any
Group of which worker belongs
certified as adults
Number of
Sr. Date of relay if Number &
Name Date of Birth Sex Residential Address Father's / Husband Name Number Remarks
No. Appointment Alphabet working date of
Nature of Work under
Assigned shifts Certificates
Section 68
of Fitness

73 0 0 0 0 0 0 0 0 0 0 0 N. A. N. A. N. A.

74 0 0 0 0 0 0 0 0 0 0 0 N. A. N. A. N. A.

75 0 0 0 0 0 0 0 0 0 0 0 N. A. N. A. N. A.

76 0 0 0 0 0 0 0 0 0 0 0 N. A. N. A. N. A.

77 0 0 0 0 0 0 0 0 0 0 0 N. A. N. A. N. A.

78 0 0 0 0 0 0 0 0 0 0 0 N. A. N. A. N. A.

79 0 0 0 0 0 0 0 0 0 0 0 N. A. N. A. N. A.

80 0 0 0 0 0 0 0 0 0 0 0 N. A. N. A. N. A.

81 0 0 0 0 0 0 0 0 0 0 0 N. A. N. A. N. A.
 Form No. 15 XYZ & CO.
(Prescribed under rule 88)
ADDRESS
Register of Adult Workers
Adolescent if any
Group of which worker belongs
certified as adults
Number of
Sr. Date of relay if Number &
Name Date of Birth Sex Residential Address Father's / Husband Name Number Remarks
No. Appointment Alphabet working date of
Nature of Work under
Assigned shifts Certificates
Section 68
of Fitness

82 0 0 0 0 0 0 0 0 0 0 0 N. A. N. A. N. A.

83 0 0 0 0 0 0 0 0 0 0 0 N. A. N. A. N. A.

84 0 0 0 0 0 0 0 0 0 0 0 N. A. N. A. N. A.

85 0 0 0 0 0 0 0 0 0 0 0 N. A. N. A. N. A.

86 0 0 0 0 0 0 0 0 0 0 0 N. A. N. A. N. A.

87 0 0 0 0 0 0 0 0 0 0 0 N. A. N. A. N. A.

88 0 0 0 0 0 0 0 0 0 0 0 N. A. N. A. N. A.

89 0 0 0 0 0 0 0 0 0 0 0 N. A. N. A. N. A.

90 0 0 0 0 0 0 0 0 0 0 0 N. A. N. A. N. A.
 Form No. 15 XYZ & CO.
(Prescribed under rule 88)
ADDRESS
Register of Adult Workers
Adolescent if any
Group of which worker belongs
certified as adults
Number of
Sr. Date of relay if Number &
Name Date of Birth Sex Residential Address Father's / Husband Name Number Remarks
No. Appointment Alphabet working date of
Nature of Work under
Assigned shifts Certificates
Section 68
of Fitness

91 0 0 0 0 0 0 0 0 0 0 0 N. A. N. A. N. A.

92 0 0 0 0 0 0 0 0 0 0 0 N. A. N. A. N. A.

93 0 0 0 0 0 0 0 0 0 0 0 N. A. N. A. N. A.

94 0 0 0 0 0 0 0 0 0 0 0 N. A. N. A. N. A.

95 0 0 0 0 0 0 0 0 0 0 0 N. A. N. A. N. A.

96 0 0 0 0 0 0 0 0 0 0 0 N. A. N. A. N. A.

97 0 0 0 0 0 0 0 0 0 0 0 N. A. N. A. N. A.

98 0 0 0 0 0 0 0 0 0 0 0 N. A. N. A. N. A.

99 0 0 0 0 0 0 0 0 0 0 0 N. A. N. A. N. A.
 Form No. 15 XYZ & CO.
(Prescribed under rule 88)
ADDRESS
Register of Adult Workers
Adolescent if any
Group of which worker belongs
certified as adults
Number of
Sr. Date of relay if Number &
Name Date of Birth Sex Residential Address Father's / Husband Name Number Remarks
No. Appointment Alphabet working date of
Nature of Work under
Assigned shifts Certificates
Section 68
of Fitness

100 0 0 0 0 0 0 0 0 0 0 0 N. A. N. A. N. A.
 IDENTITY CARD REGISTER

XYZ & CO.

ADDRESS

Date of
Recent Passport Signature or Signature of
Sr. Full Name of the Address of the Date of Birth of Joinning the Date of
Size Photograph of Thumb Impression Manager or Remark
No. Employee Employee the Employee Service if the Issue
the Employee of the Employee Authorised Agent
Factory

1 0 0 0 0 0 0 0 0

2 0 0 0 0 0 0 0 0

3 0 0 0 0 0 0 0 0
 IDENTITY CARD REGISTER

XYZ & CO.

ADDRESS

Date of
Recent Passport Signature or Signature of
Sr. Full Name of the Address of the Date of Birth of Joinning the Date of
Size Photograph of Thumb Impression Manager or Remark
No. Employee Employee the Employee Service if the Issue
the Employee of the Employee Authorised Agent
Factory

4 0 0 0 0 0 0 0 0

5 0 0 0 0 0 0 0 0

6 0 0 0 0 0 0 0 0
 IDENTITY CARD REGISTER

XYZ & CO.

ADDRESS

Date of
Recent Passport Signature or Signature of
Sr. Full Name of the Address of the Date of Birth of Joinning the Date of
Size Photograph of Thumb Impression Manager or Remark
No. Employee Employee the Employee Service if the Issue
the Employee of the Employee Authorised Agent
Factory

7 0 0 0 0 0 0 0 0

8 0 0 0 0 0 0 0 0

9 0 0 0 0 0 0 0 0
 IDENTITY CARD REGISTER

XYZ & CO.

ADDRESS

Date of
Recent Passport Signature or Signature of
Sr. Full Name of the Address of the Date of Birth of Joinning the Date of
Size Photograph of Thumb Impression Manager or Remark
No. Employee Employee the Employee Service if the Issue
the Employee of the Employee Authorised Agent
Factory

10 0 0 0 0 0 0 0 0

11 0 0 0 0 0 0 0 0

12 0 0 0 0 0 0 0 0
 IDENTITY CARD REGISTER

XYZ & CO.

ADDRESS

Date of
Recent Passport Signature or Signature of
Sr. Full Name of the Address of the Date of Birth of Joinning the Date of
Size Photograph of Thumb Impression Manager or Remark
No. Employee Employee the Employee Service if the Issue
the Employee of the Employee Authorised Agent
Factory

13 0 0 0 0 0 0 0 0

14 0 0 0 0 0 0 0 0

15 0 0 0 0 0 0 0 0
 IDENTITY CARD REGISTER

XYZ & CO.

ADDRESS

Date of
Recent Passport Signature or Signature of
Sr. Full Name of the Address of the Date of Birth of Joinning the Date of
Size Photograph of Thumb Impression Manager or Remark
No. Employee Employee the Employee Service if the Issue
the Employee of the Employee Authorised Agent
Factory

16 0 0 0 0 0 0 0 0

17 0 0 0 0 0 0 0 0

18 0 0 0 0 0 0 0 0
 IDENTITY CARD REGISTER

XYZ & CO.

ADDRESS

Date of
Recent Passport Signature or Signature of
Sr. Full Name of the Address of the Date of Birth of Joinning the Date of
Size Photograph of Thumb Impression Manager or Remark
No. Employee Employee the Employee Service if the Issue
the Employee of the Employee Authorised Agent
Factory

19 0 0 0 0 0 0 0 0

20 0 0 0 0 0 0 0 0

21 0 0 0 0 0 0 0 0
 IDENTITY CARD REGISTER

XYZ & CO.

ADDRESS

Date of
Recent Passport Signature or Signature of
Sr. Full Name of the Address of the Date of Birth of Joinning the Date of
Size Photograph of Thumb Impression Manager or Remark
No. Employee Employee the Employee Service if the Issue
the Employee of the Employee Authorised Agent
Factory

22 0 0 0 0 0 0 0 0

23 0 0 0 0 0 0 0 0

24 0 0 0 0 0 0 0 0
 IDENTITY CARD REGISTER

XYZ & CO.

ADDRESS

Date of
Recent Passport Signature or Signature of
Sr. Full Name of the Address of the Date of Birth of Joinning the Date of
Size Photograph of Thumb Impression Manager or Remark
No. Employee Employee the Employee Service if the Issue
the Employee of the Employee Authorised Agent
Factory

25 0 0 0 0 0 0 0 0

26 0 0 0 0 0 0 0 0

27 0 0 0 0 0 0 0 0
 IDENTITY CARD REGISTER

XYZ & CO.

ADDRESS

Date of
Recent Passport Signature or Signature of
Sr. Full Name of the Address of the Date of Birth of Joinning the Date of
Size Photograph of Thumb Impression Manager or Remark
No. Employee Employee the Employee Service if the Issue
the Employee of the Employee Authorised Agent
Factory

28 0 0 0 0 0 0 0 0

29 0 0 0 0 0 0 0 0

30 0 0 0 0 0 0 0 0
 IDENTITY CARD REGISTER

XYZ & CO.

ADDRESS

Date of
Recent Passport Signature or Signature of
Sr. Full Name of the Address of the Date of Birth of Joinning the Date of
Size Photograph of Thumb Impression Manager or Remark
No. Employee Employee the Employee Service if the Issue
the Employee of the Employee Authorised Agent
Factory

31 0 0 0 0 0 0 0 0

32 0 0 0 0 0 0 0 0

33 0 0 0 0 0 0 0 0
 IDENTITY CARD REGISTER

XYZ & CO.

ADDRESS

Date of
Recent Passport Signature or Signature of
Sr. Full Name of the Address of the Date of Birth of Joinning the Date of
Size Photograph of Thumb Impression Manager or Remark
No. Employee Employee the Employee Service if the Issue
the Employee of the Employee Authorised Agent
Factory

34 0 0 0 0 0 0 0 0

35 0 0 0 0 0 0 0 0

36 0 0 0 0 0 0 0 0
 IDENTITY CARD REGISTER

XYZ & CO.

ADDRESS

Date of
Recent Passport Signature or Signature of
Sr. Full Name of the Address of the Date of Birth of Joinning the Date of
Size Photograph of Thumb Impression Manager or Remark
No. Employee Employee the Employee Service if the Issue
the Employee of the Employee Authorised Agent
Factory

37 0 0 0 0 0 0 0 0

38 0 0 0 0 0 0 0 0

39 0 0 0 0 0 0 0 0
 IDENTITY CARD REGISTER

XYZ & CO.

ADDRESS

Date of
Recent Passport Signature or Signature of
Sr. Full Name of the Address of the Date of Birth of Joinning the Date of
Size Photograph of Thumb Impression Manager or Remark
No. Employee Employee the Employee Service if the Issue
the Employee of the Employee Authorised Agent
Factory

40 0 0 0 0 0 0 0 0

41 0 0 0 0 0 0 0 0

42 0 0 0 0 0 0 0 0
 IDENTITY CARD REGISTER

XYZ & CO.

ADDRESS

Date of
Recent Passport Signature or Signature of
Sr. Full Name of the Address of the Date of Birth of Joinning the Date of
Size Photograph of Thumb Impression Manager or Remark
No. Employee Employee the Employee Service if the Issue
the Employee of the Employee Authorised Agent
Factory

43 0 0 0 0 0 0 0 0

44 0 0 0 0 0 0 0 0

45 0 0 0 0 0 0 0 0
 IDENTITY CARD REGISTER

XYZ & CO.

ADDRESS

Date of
Recent Passport Signature or Signature of
Sr. Full Name of the Address of the Date of Birth of Joinning the Date of
Size Photograph of Thumb Impression Manager or Remark
No. Employee Employee the Employee Service if the Issue
the Employee of the Employee Authorised Agent
Factory

46 0 0 0 0 0 0 0 0

47 0 0 0 0 0 0 0 0

48 0 0 0 0 0 0 0 0
 IDENTITY CARD REGISTER

XYZ & CO.

ADDRESS

Date of
Recent Passport Signature or Signature of
Sr. Full Name of the Address of the Date of Birth of Joinning the Date of
Size Photograph of Thumb Impression Manager or Remark
No. Employee Employee the Employee Service if the Issue
the Employee of the Employee Authorised Agent
Factory

49 0 0 0 0 0 0 0 0

50 0 0 0 0 0 0 0 0

51 0 0 0 0 0 0 0 0
 IDENTITY CARD REGISTER

XYZ & CO.

ADDRESS

Date of
Recent Passport Signature or Signature of
Sr. Full Name of the Address of the Date of Birth of Joinning the Date of
Size Photograph of Thumb Impression Manager or Remark
No. Employee Employee the Employee Service if the Issue
the Employee of the Employee Authorised Agent
Factory

52 0 0 0 0 0 0 0 0

53 0 0 0 0 0 0 0 0

54 0 0 0 0 0 0 0 0
 IDENTITY CARD REGISTER

XYZ & CO.

ADDRESS

Date of
Recent Passport Signature or Signature of
Sr. Full Name of the Address of the Date of Birth of Joinning the Date of
Size Photograph of Thumb Impression Manager or Remark
No. Employee Employee the Employee Service if the Issue
the Employee of the Employee Authorised Agent
Factory

55 0 0 0 0 0 0 0 0

56 0 0 0 0 0 0 0 0

57 0 0 0 0 0 0 0 0
 IDENTITY CARD REGISTER

XYZ & CO.

ADDRESS

Date of
Recent Passport Signature or Signature of
Sr. Full Name of the Address of the Date of Birth of Joinning the Date of
Size Photograph of Thumb Impression Manager or Remark
No. Employee Employee the Employee Service if the Issue
the Employee of the Employee Authorised Agent
Factory

58 0 0 0 0 0 0 0 0

59 0 0 0 0 0 0 0 0

60 0 0 0 0 0 0 0 0
 IDENTITY CARD REGISTER

XYZ & CO.

ADDRESS

Date of
Recent Passport Signature or Signature of
Sr. Full Name of the Address of the Date of Birth of Joinning the Date of
Size Photograph of Thumb Impression Manager or Remark
No. Employee Employee the Employee Service if the Issue
the Employee of the Employee Authorised Agent
Factory

61 0 0 0 0 0 0 0 0

62 0 0 0 0 0 0 0 0

63 0 0 0 0 0 0 0 0
 IDENTITY CARD REGISTER

XYZ & CO.

ADDRESS

Date of
Recent Passport Signature or Signature of
Sr. Full Name of the Address of the Date of Birth of Joinning the Date of
Size Photograph of Thumb Impression Manager or Remark
No. Employee Employee the Employee Service if the Issue
the Employee of the Employee Authorised Agent
Factory

64 0 0 0 0 0 0 0 0

65 0 0 0 0 0 0 0 0

66 0 0 0 0 0 0 0 0
 IDENTITY CARD REGISTER

XYZ & CO.

ADDRESS

Date of
Recent Passport Signature or Signature of
Sr. Full Name of the Address of the Date of Birth of Joinning the Date of
Size Photograph of Thumb Impression Manager or Remark
No. Employee Employee the Employee Service if the Issue
the Employee of the Employee Authorised Agent
Factory

67 0 0 0 0 0 0 0 0

68 0 0 0 0 0 0 0 0

69 0 0 0 0 0 0 0 0
 IDENTITY CARD REGISTER

XYZ & CO.

ADDRESS

Date of
Recent Passport Signature or Signature of
Sr. Full Name of the Address of the Date of Birth of Joinning the Date of
Size Photograph of Thumb Impression Manager or Remark
No. Employee Employee the Employee Service if the Issue
the Employee of the Employee Authorised Agent
Factory

70 0 0 0 0 0 0 0 0

71 0 0 0 0 0 0 0 0

72 0 0 0 0 0 0 0 0
 IDENTITY CARD REGISTER

XYZ & CO.

ADDRESS

Date of
Recent Passport Signature or Signature of
Sr. Full Name of the Address of the Date of Birth of Joinning the Date of
Size Photograph of Thumb Impression Manager or Remark
No. Employee Employee the Employee Service if the Issue
the Employee of the Employee Authorised Agent
Factory

73 0 0 0 0 0 0 0 0

74 0 0 0 0 0 0 0 0

75 0 0 0 0 0 0 0 0
 IDENTITY CARD REGISTER

XYZ & CO.

ADDRESS

Date of
Recent Passport Signature or Signature of
Sr. Full Name of the Address of the Date of Birth of Joinning the Date of
Size Photograph of Thumb Impression Manager or Remark
No. Employee Employee the Employee Service if the Issue
the Employee of the Employee Authorised Agent
Factory

76 0 0 0 0 0 0 0 0

77 0 0 0 0 0 0 0 0

78 0 0 0 0 0 0 0 0
 IDENTITY CARD REGISTER

XYZ & CO.

ADDRESS

Date of
Recent Passport Signature or Signature of
Sr. Full Name of the Address of the Date of Birth of Joinning the Date of
Size Photograph of Thumb Impression Manager or Remark
No. Employee Employee the Employee Service if the Issue
the Employee of the Employee Authorised Agent
Factory

79 0 0 0 0 0 0 0 0

80 0 0 0 0 0 0 0 0

81 0 0 0 0 0 0 0 0
 IDENTITY CARD REGISTER

XYZ & CO.

ADDRESS

Date of
Recent Passport Signature or Signature of
Sr. Full Name of the Address of the Date of Birth of Joinning the Date of
Size Photograph of Thumb Impression Manager or Remark
No. Employee Employee the Employee Service if the Issue
the Employee of the Employee Authorised Agent
Factory

82 0 0 0 0 0 0 0 0

83 0 0 0 0 0 0 0 0

84 0 0 0 0 0 0 0 0
 IDENTITY CARD REGISTER

XYZ & CO.

ADDRESS

Date of
Recent Passport Signature or Signature of
Sr. Full Name of the Address of the Date of Birth of Joinning the Date of
Size Photograph of Thumb Impression Manager or Remark
No. Employee Employee the Employee Service if the Issue
the Employee of the Employee Authorised Agent
Factory

85 0 0 0 0 0 0 0 0

86 0 0 0 0 0 0 0 0

87 0 0 0 0 0 0 0 0
 IDENTITY CARD REGISTER

XYZ & CO.

ADDRESS

Date of
Recent Passport Signature or Signature of
Sr. Full Name of the Address of the Date of Birth of Joinning the Date of
Size Photograph of Thumb Impression Manager or Remark
No. Employee Employee the Employee Service if the Issue
the Employee of the Employee Authorised Agent
Factory

88 0 0 0 0 0 0 0 0

89 0 0 0 0 0 0 0 0

90 0 0 0 0 0 0 0 0
 IDENTITY CARD REGISTER

XYZ & CO.

ADDRESS

Date of
Recent Passport Signature or Signature of
Sr. Full Name of the Address of the Date of Birth of Joinning the Date of
Size Photograph of Thumb Impression Manager or Remark
No. Employee Employee the Employee Service if the Issue
the Employee of the Employee Authorised Agent
Factory

91 0 0 0 0 0 0 0 0

92 0 0 0 0 0 0 0 0

93 0 0 0 0 0 0 0 0
 IDENTITY CARD REGISTER

XYZ & CO.

ADDRESS

Date of
Recent Passport Signature or Signature of
Sr. Full Name of the Address of the Date of Birth of Joinning the Date of
Size Photograph of Thumb Impression Manager or Remark
No. Employee Employee the Employee Service if the Issue
the Employee of the Employee Authorised Agent
Factory

94 0 0 0 0 0 0 0 0

95 0 0 0 0 0 0 0 0

96 0 0 0 0 0 0 0 0
 IDENTITY CARD REGISTER

XYZ & CO.

ADDRESS

Date of
Recent Passport Signature or Signature of
Sr. Full Name of the Address of the Date of Birth of Joinning the Date of
Size Photograph of Thumb Impression Manager or Remark
No. Employee Employee the Employee Service if the Issue
the Employee of the Employee Authorised Agent
Factory

97 0 0 0 0 0 0 0 0

98 0 0 0 0 0 0 0 0

99 0 0 0 0 0 0 0 0
 IDENTITY CARD REGISTER

XYZ & CO.

ADDRESS

Date of
Recent Passport Signature or Signature of
Sr. Full Name of the Address of the Date of Birth of Joinning the Date of
Size Photograph of Thumb Impression Manager or Remark
No. Employee Employee the Employee Service if the Issue
the Employee of the Employee Authorised Agent
Factory

100 0 0 0 0 0 0 0 0
Sr. No. STATE CODE STATE NAME
1 AP ANDHRA PRADESH
2 AR ARUNACHAL PRADESH
3 AS ASSAM
4 BH BIHAR
5 CG CHATTISGARH
6 CH CHANDIGARH
7 DL DELHI
8 GA GOA
9 GJ GUJARAT
10 HP HIMACHAL PRADESH
11 HR HARYANA
12 JH JHARKHAND
13 JK JAMMU AND KASHMIR
14 KL KERALA
15 KN KARNATAKA
16 MG MEGHALAYA
17 MH MAHRASHTRA
18 MN MANIPUR
19 MP MADHYA PRADESH
20 MZ MIZORAM
21 NL NAGALAND
22 OR ORISSA
23 PB PUNJAB
24 PN PONDICHERRY
25 RJ RAJASTHAN
26 SK SIKKIM
27 TN TAMILNADU
28 TR TRIPURA
29 UC UTTARANCHAL
30 UP UTTAR PRADESH
31 WB WEST BENGAL
32 AN ANDMAN & NICOBAR ISLAND
33 DD DAMAN & DIU
34 DN DADRA & NAGAR HAVELI
35 LD LAKSHADWEEP