DECLARATION PARTICULARS OF THE MEMBER a) Name ofthe Member b) Father's/Husband’s Name ©) PEAICNo. 4. Scheme Certificate No. ©) Date of birth of the mémber (Asper Scheme Certificate) ) . Marital Status ofthe Member ‘Un-married/Married/ Widow/ Widower CERTIFICATE FROM MEMBER FOR MEMBER PENSION, | certify that I have neither employed prior to joining nor taken any employment after the date of my exit from the present service to till date of this application in any covered establishment under the Employees’ Provident Fund & Miscellaneous Provisions Act, 1952. Date: Place: ‘Signature / thumb impression of claimant CERTIFICATE FROM WIDOW/CLAIMANT FOR WIDOW PENSION/CHILDREN PENSION/ORPHAN PENSION i) Applicant's Name (Widow/Widower/Guardian) : {certify that the deceased member has neither employed prior to joining nor taken any employment after the date of his exit from the service to till date of this application in any covered establishment under the Employecs' Provident Funds & Miscellaneous Provisions Act, 1952. Ihave also not claim Peisionary Benefits except from this establishment and also will not claim in future from any other covered establishment under the Employees's Provi- dent Fund & Miscellaneous Provisions Act, 1952. Date: Plate: o ‘Signature /thumb impression ofclaimant