FORM NO-9 (REVISED)

THE EMPLOYEES’ PROVIDENT FUNDS SCHEME, 1952 (PARA 36(1)) AND THE EMPLOYEES’ PENSION SCHEME, 1995
(PARA 20)
(PARA 16(1) RETURN OF EMPLOYEES WHO ARE ENTITLED AND REQUIRED TO BECOME MEMBERS OF THE
EMPLOYEES’ PROVIDENT FUND AND PENSION FUND (GUJARAT REGION)

Name and Address of Fact/Estt. Code No. GJ/

Date of Coverage
Industry in which the Fact. / Estt. If factory / Estt. Is covered under
is engaged ESI. Act. Indicate the Code No. allotted under E.S.I.C.
E.S.I. Code No.____________

Sr. Account Name of Father’s Date Sex Date of Total period of Machine/Foli Initials of Date and D.C. S.S.

No No. GJ/ employe Name (or Of eligibility for previous o No of S.S. reason of A.A.O. /
A.C.
e (in husband’s Birth membership service Ledger Card living
Remarks
block name in case (Excluding Opened service
and Initial
capital) of married period of
on
women break) as on settlement
date of joining
the fund
1 2 3 4 5 6 7 8 9 10 11 12