New Form No.-11 ~ Declaration Form (Tobe etained by the employer for future reference) EMPLOYEES’ PROVIDENT FUND ORGANISATION Empleyos' Provident Furds Scheme, 1952 (Paragraph 248 67)& Employees’ Ponain Sovame, 1905 (Paragiash 24) (Deciaraton by a person tzking up employment in any establishment on which EPF Scheme, 1952 and for EPS, 1985's appllcabo) 4, | Name of the member Father's Name [—] Spouse's Name [] | | (Please tick whichever Is applicable) 3 | dae ofr: (097 une. 4 | Gender: (Male/Female/Transgender) 15] Matar Saas Carried 6 |@) Emaillo: ~ |__[(e) modite ne. TFT Wether easier a member 1952 “a. | Whether earlier a member of Employees’ Pension Scheme, 1995 |) Previous employment details: [if Yes to 7 AND/OR 8 above] 2) Universal Accourt Number: | 3) Previous °F Account Number: ©) _Date of exit from previcus employment: (DD/MM/YYYY) 1G) Scheme Cerificate No. (issued) Se PO a) “a Vaidy 0° passport (ODTRMIAYYY to OMA “KYC Details (aac sf attested covies of Flowing KYCS) 11 |) Baikhccount We, BFS ade ,—___ 3) _AADHAR Wuribar [2 Permanent Account Number (PAN), avaliable 2) Certifies tha the particulars are true to the best of my knowledge. 2}, athonize EPFO to use my Aachar for venfcaton/asthenticaion eK purpose for service deivery 4] Kindly transfer the funds ard service deals, if applicable, foro the prevous PF account as declared above tothe present PF. Account, (The transfe: would be possibe only F the identified KYC detal approved by previous employer tas beon verified by present employer using hs Digital Sgrature Cerarcate) 4|_ Incase of changes in above details, the seme will be intimates to employer at the earliest ate Pace ‘Signature of Member (DECLARATION BY PRESENT EMPLOYER AL The member Mess fas ined on and ras been allotted PF Number 8. In case the persan was earlier not a rember of £PF Scherne, 1952 and EPS, 1995 ‘+ (Post allotment of UAN) The UA alictted for the member is + Please Tick the Appropriate Option: ‘The KYC detals ofthe above member in the JAN database 1 Have not been uploads Have boon voleaded but not approved | Have been uploaded end approved with OSC Incase me person was earlier a member of EFF Scheme, 1952 and £PS, 1995: ‘+The a2ave PF Account numtber/JAN of the memine- as mentioned in (A) above nas been tagged with risjher UAN/Previous Mernzer ID as declared by member. ‘+ Please Tick the Appropriate Opti © The XYC detais of the above member in the UAN datahase have been appraved with Distal Signature Certficate anc transfer request has been generated or portal [As be DSC of establishment are not registred with EPFO, the member has beer informed to file physical cam (Form= 23) for trensferof funds from his previous estab shent. Date: Signeture of Employer with Seal of Establishment