Form 11 (Revised)

Mandatory

Employee Code__________

THE EMPLOYEES PROVIDENT FUNDS SCHEME, 1952 (Paragraph 34) AND THE EMPLOYEES PENSION SCHEME, 1995 (Paragraph 24) Decl ar atio n by a perso n tak in g up employ me n t in an establ is h m e n t in which the Employee s Provide n t Fund s & Employee s Pensio n Sche me enforce

(Name of Employee)

Son/ wife/ daughter of* Sh.

do hereby solemnly declare that :-

(a)

I was employed in M/s and left service on

(Name and Full Address of the immediate previous employer) (Date of leaving with immediate previous employer)

prior to that, I was employed in

to

(Name and Full Address of the second last employer, if any)

fro m

(Date of joining & leaving with second last employer, if any)

(b)

I was member of

(Name of PF Trust / Address of PF Office of immediate previous employer )

Provident Fund and also/but not* of the Pension Fund and my account number (s) was/were

fro m

to

(Date of joining & leaving with immediate previous employer).

(PF No. with Establishment Code of immediate previous employer)

(c) (d) (e) (f) (g) (h)

Date

I have / have not * withdrawn the amount of my Provident Fund/Pension Fund. I have / have not *drawn any superannuation benefits in respect of my past service from any employer. I have / have never * been a member of any Provident Fund and/or Pension Fund. I am drawing / not drawing * Pension under EPS 95. I am a holder / not holder * of scheme Certificate. Scheme certificate surrendered / not surrendered *.

*Strike out whichever is not applicable.

(Date of joining of employee)

Signature or left hand thumb impression of the employee

Shri/Smt .
in M/s

(Name of Employee)

is appointed as with effect

(Designation with Co.)

(Name of the present employer )

(Date of appointment) Form 11

from P.F. Account Number Date

(Date of joining of employee) (PF No. with Estt. Code of present employer)

Signature of the Employer/Manager or Other Authorised Officer with Office Seal

Form 11