For Office use only Regd.No.

EMPLOYEE'S PROVIDENT FUND SCHEME,1952

Form----19
Form to be used by a major member of the Employees Provident Fund Scheme,1952 for claiming the
Employees Provident Fund dues (Para 72) (5)
1. Name of the member

2. Father's / Husband Name

3. Name and Address of the Factory/Establishment CLEAN CONCEPT (I) PVT.LTD.

in which the member was last employed. C-9 ,2nd Floor,Amar Colony Mkt.
Lajpat Nagar-IV,New Delhi-110024.
4. Account No. PN/HR

5. Date of leaving services

6. Reason of leaving Services

7. Full Postal address (in Block Letters0

8. Mode of Remittance Put a 'Tick in box against the one opted

a. By postal Money order at my cost. To the address given against item No.7
S.B.Account No.
b. By account payees cheque sent Direct for credit Name of the Bank
to my S.B. A/C (Scheduled Bank / P.O Branch
under intimation to me. Full address of the Branch

Advance Stamped Receipt furnished below

Certified that the Particularsare true to the best of my Knowledge
Date of Joining the Establishment
Date Of Birth
Contribution for the Current Financial Year
Month Contribution Period of Break if any

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