Form 11 (Revised) of Employee Code © @ fe) 0 @ (h) Mandatory ‘THE EMPLOYEES’ PROVIDENT FUNDS SCHEME, 1952 (Paragraph 34) AND ‘THE EMPLOYEES’ PENSION SCHEME, 1995 (Paragraph 24) Declaration by a person taking up employment in an establishment in which the Employees’ Provident Funds & Employees’ Pension Scheme enforce Son! wie’ daughter of *Sh, ‘ane af Fpayee) dohereby solermniy declare that > | was employed in Mis ‘ie and Fa ress a a te povous employe) and left sence on Prior to that | was employed in Bite a esng wit naa preions employe) ‘fom Tie ad Fa Eas oa SE TOO TaTHT {Bate of ening leaving with secon last omploye, ity) | was member of ToT PF Tas Ras TPF OCT Wome rans BmpTOVTT Provident Fund and alsolbut not” ofthe Pension Fund fom to (@ate of ning leaving with nmectos previous employer ‘and my account number(s) wasiwere {PF Ro wih Estas Cade of Tama revans enpvoya {have / have not* withdrawn the amount of my Provident Fund/Pension Fund. have / have not*cawn any superannuation benefits in respect of my gas service frm any employe. ‘have / have never* béen a member of ny Provident Fund and/or Penson Fund. 1amdrawing / not drawina* Pension under EPS 95. ama holder { not holder* of scheme Cerio. Scheme cefiate surrendered / not surrendered’. “Strike out whichever is not applicable. Date Se ‘Signature oF left hand thumb Mate oon of erpoyee) impression of the employee ‘Smt is appointed as ae Basignatan wi Coy ints PF. Date ‘Wiame of the presamt amployer ) en ‘Date of appeintinend ‘Account Number “TF arsaih Tae Code aT eSeR TOF (ate ofjng of preys) Signature of the Employerittanager or Other ‘Authorised Officer with Office Seal