INSTRUCTIONS FOR FILLING THE FORM

1. Please follow the guideline comments for entering information, wherever provided.

2. Please enter ALL details in BLOCK letters, except for email address.

3. Please ensure all information being captured is correct.

4. Please use TAB to move from one field to the other, to go back use SHIFT+TAB

5. Certain details such as Name, Date of Birth, Marital Status, Nominee details etc. once
captured, will automatically reflect in the other sheets where required

6. Please fill family details correctly. If family details are not entered correctly,
the nominee details wherever applicable, will not be captured properly.

7. If information provided / entered is incorrect, it will reflect in ORANGE color.

Incorrect details must be rectified before printing and signing the form.

8. After filling the form, please sign wherever the numbers have been provided. For e.g 1
 DOCUMENTS CHECK - LIST

Emp Name Applicant No.

HR RM TA RM
Grade - DOJ

Sr No. Documents Pending Received

1 Accepted Copy Of Appointment Letter with Salary Break Up Sheet

2 Employee Data Form

3 PF Nomination Form ( 2 Signs )

4 PF Declaration Form ( 1Sign ) UAN no or PF no

5 Gratuity Nomination Form ( 1 Sign )

6 Life Cover Beneficiary Form (1 Sign )

7 ID Card Application ( Photo & Blood Group )

8 Acknowledgement Of Share Dealing Code

9 Acknowledgement Of Corporate Code Of Conduct

10 IT Security Form

11 Self Declaration for Medical Fitness

12 PAN Card/ Form 60/ Form 49A

13 Qualification Marksheet And Certificate**

14 Address Proof (pls check with emp data form)*

15 Notice Period Letter/ Bonus Letter (If Applicable )

16 Commitment Letter/ IRDA Letter (If Applicable )

17 Resignation Acceptance/ Relieving / Experience Letter (Not Applicable for Freshers )

18 3 Passport Size Photographs

Note:
DOB Proof: 1. Birth Certificate (or) 2. School Leaving Certificate (or) 3. 10th Mark sheet (or) 4. Passport
**Education Qualification: Graduation Marksheets & Certificates
*Address Proof: Passport (or) Adhaar (or) Driving Licence (Except Maharashtra) (or) Electricity Bill (or) Bank Statement
(or) Gas / Water Bill (or) Registered Rent Agreement

<<< SIGN HERE 01-JAN-2021

14 Employee Signature Date
1
 Please paste your
passport size
photograph
Employee Data Form with white
background

Name KUMAR MANISH KIRAN

(In Block Letters)
SURNAME FIRST NAME MIDDLE NAME

Father's Name KUMAR KIRAN AJAY

(MANDATORY)
SURNAME FIRST NAME MIDDLE NAME
Date of Birth 15 DEC 1980 Gender MALE

Nationality INDIAN Category GENERAL

PAN No. ABCPK1234W Passport No. (MENTION IF AVAILABLE)

UAN (NA for fresher) 1234567891 Aadhar No. 123456789012

Marital Status MARRIED Blood Group B POSITIVE

Domicile MAHARASHTRA Religion HINDUISM

Personal Email ID manishkumar@gmail.com Mobile No. 8889996666

Residential Address (MENTION FULL ADDRESS WITH CITY, STATE, & PINCODE FOR CURRENT RESIDENTIAL ADDRESS)

A/304 ARUN APARTMENTS NARAYAN MHATRE ROAD DAHISAR WEST MUMBAI 400068

Telephone Number Pincode 400068

Permanent Address

IF ADDRESS MENTIONED ON AADHAR CARD IS DIFFERENT FROM RESIDENTAIL ADDRESS MENTIONED ABOVE THEN
UPDATE ADDRESS AS PER AADHAR HERE AS PERMANENT ADDRESS

Telephone Number Pincode

2
Family Details & Medical Insurance Nomination
Dependent for
Date Of Birth
Sr No Name of Family Member Mediclaim (Yes / Relationship Occupation
DD MM YYYY
No)
1 MANISHA KUMARI YES WIFE 7 4 1981 SERVICE
2 MANAS KUMAR YES SON 9 8 2009
3 MANASI KUMARI YES DAUGHTER 22 2 2012
4 ASHADEVI YES MOTHER 12 11 1951 HOUSEWIFE
5 KIRAN KUMAR YES FATHER 9 5 1950 RETIRED
6
7 UPDATE YOUR FAMILY MEMBERS DETAILS FOR SPOUSE, DAUGHTER, SON, MOTHER, FATHER
IF THEY ARE DEPENDENT ON YOU MENTION AS "YES"
8 >>> ABOVE DETAILS ARE GIVEN AS AN EXAMPLES <<<

Academic Details (Begin with last qualification)

Month & School / College /
Degree / University / % of
Year of Subject of Specialisation Institute and
Diploma Board Marks
Passing Location
NAME OF THE NAME OF THE
MAR 2000 B.COM ACCOUNTS, TAX, ECO %/ GRADE
COLLEGE/INSTITUTION UNIVERSITY
NAME OF THE NAME OF THE
MAR 1998 HSC ACCOUNTS, ECO %/ GRADE
COLLEGE/INSTITUTION UNIVERSITY
NAME OF THE NAME OF THE
MAR 1995 SSC ENG, HISTORY %/ GRADE
COLLEGE/INSTITUTION UNIVERSITY

YYYY : PASSING YEAR IN 4 DIGIT E.G. 2018 | UPDATE QUALIFICATION DETAILS IN DESCENDING ORDER STARTING FROM
HIGHEST QUALIFICATION
>>> ABOVE DETAILS ARE GIVEN AS AN EXAMPLES <<<

Experience Records (Begin with last employment)

From To
Organisation Name Position(s) held Reason for leaving
MM YY MM YY
MAY 2018 DEC 2020 HDFC BANK LIMITED SENIOR EXECUTIVE BETTER PROSPECT

JUL 2015 APR 2018 ICICI BANK LIMITED EXECUTIVE BETTER PROSPECT

UPDATE THE EXPERIENCE DETAILS IN DESCENDING ORDER

>>> ABOVE DETAILS ARE GIVEN AS AN EXAMPLES <<<

3
Employment Details of Last Employment
Last Employment (Emp 1) Prior to Last Employment (Emp 2)
HDFC BANK LIMITED ICICI BANK LIMITED
Employer Name and full
ICICI TOWER, BKC, BANDRA EAST, MUMBAI
address HDFC TOWER, NM MARG, MUMBAI 400001
400055

Office Landline Numbers 022 43567654 022 67656883

Dates Employed 1 MAY 2018 to 31 DEC 2020 1 JUL 2015 to 30 APR 2018
Job Title / Designation SENIOR EXECUTIVE EXECUTIVE
Gross Salary 180,000/- 150,000/-
Supervisor Name ASHOK KUMAR KISHOR KUMAR
Supervisor Mobile No. 8889997771 9998887771
Reason for Leaving BETTER PROSPECTS BETTER PROSPECTS
Employee Code 1234561 876782
HR Contact Name RAKESH KUMAR ANUSHKA VERMA
HR Contact Email RAKESHKUMAR123@HDFC.COM ANUSHKAVERMA@ICICI.COM

Update all the fields above, if work experience is for 2 or more entities mentioned the details in both the
columns and update the reference details inbelow table

Reference Details for Professional Reference Checks (Not applicable for Freshers)
Reference 1 Reference 2

Reference Name ANIL KAPOOR VISHAL BHARDWAJ

Reference Designation SENIOR MANAGER MANAGER
Reference Organisation
HDFC BANK ICICI BANK
Name
Landline Number 022-1234 5667 022 - 3425 8767
Mobile Number 9898987676 8787678701
Period for which he/she
MAY-18 TO DEC-20 JUL-15 TO APR-18
knows the candidate
Association with the
SUPERVISOR SUPERVISOR
candidate

DECLARATION AND AUTHORIZATION

I hereby authorize Kotak Mahindra Group of companies (or a third party agent by the Company) to
contact any former employers as indicated above and carry out all Background checks not restricted to
education and employment deemed appropriate through this selection procedure. I authorize former
employers, agencies, educational institution etc. to release any information pertaining to my
employment / education and I release them from any liablity in doing so.

I confirm that the above information is correct to the best of knowledge and I understand that any
misrepresentation of information on this application form may, in the event of my obtaining
employment, result in action based on the company policy.

4
 SELECT FROM DROPDOWN
Do you have any of your relatives working with Kotak Group companies or its subsidiaries ? NO

If yes, please provide the below details

Relationship with Name of the Employee code

Name of the person Position
the person Company (if available)

>>> IF ANY RELATIVE IS WORKING WITH KOTAK GROUP PLS PROVIDE THE DETAILS HERE <<<

Contact Person (In case of Emergency)

Sr No Name Address Tel . Number Cell Number

1 MANISHA KUMARI FULL ADDRESS 022 - 1234 7867 9999888866

2 KIRAN KUMAR FULL ADDRESS 022 - 1234 7867 7777888878

3 ANUPAM KHER FULL ADDRESS 022 - 3234 5934 6667778889

>>> Update the emergency contact (family members, Friends, relatives) <<<

Do you have existing KOTAK Customer Relationship Number (CRN)

CRN: A/c No:

I, - hereby declare that the information mentioned above
is true to the best of my knowledge .I shall be solely responsible for any discrepancy / misleading
statements and also it is upon me to communicate any additions / changes to the above information
to the HR in writing .

1 Signature : <<< SIGN HERE

Date : 01-JAN-2021 Place

5
 FORM 2 (REVISED)
NOMINATION AND DECLARATION FORM FOR For Office use only
UNEXEMPTED / EXEMPTED ESTABLISHMENT Inward No:
Declaration and Nomination Form under the Employee's Group No.:
Provident Fund & Employee's Pension scheme Office At.:
(Paragraph 33 & 61(1) of the Employees' Provident Fund Scheme,
1952 & paragraph 18 of the Employees' Pension Scheme, 1995)

1 . Name (In Block Letters) MANISH KIRAN KUMAR

2 . Father's/ Husband's Name KIRAN AJAY KUMAR

3 . Date of Birth 15-DEC-1980 4 . Sex MALE

5 . Marital Status MARRIED 6 . Account No

(married / unmarried / widow / widower)
7 . Address
Permanent
>>> AUTO-FILLED FROM THE EMPLOYEE DATA FORM <<< IF NOT

Temporary
A/304 ARUN APARTMENTS NARAYAN MHATRE ROAD DAHISAR WEST MUMBAI 400068-400068

PART -A (EPF)
I hereby nominate the person(s) / cancel the nomination made by me previously & nominate the person(s)
mentioned below to receive the amount standing to my credit in Employees' Provident Fund, in the event of my death

If the nominee is a minor,

Total amount or
name & relationship &
Nominee's share of
address of the guardian
Name of the Nominees Address relationship with Date of Birth accumula-tions in
who may receive the
the member Provident Fund
amount during the
to be paid to
minority of nominee
each nominee
1 2 3 4 5 6
A/304 ARUN APARTMENTS
NARAYAN MHATRE ROAD
MANISHA KUMARI DAHISAR WEST MUMBAI WIFE 7 4 1981 100
400068-400068

>>> SELECT THE NOMINEE, ADDRESS FROM THE DROP DOWN | IF ADDRESS IS DIFFERENT THEN PLS MENTION FULL
ADDRESS | TOTAL % OF SHARE SHOULD BE 100% <<<

1. * Certified that I have no family as denied in para2(g) of the Employee's Provident fund Scheme ,1952
and should I acquire a family hereafter the above nomination should be deemed as cancalled.
2. * Certified that my father / mother is / are dependent upon me.
<<< SIGN HERE
* Strike out which ever is not applicable 2 Signature or thumb impression of the subscriber
(P.T.O)
6
 PART-B (EPS)
Para 18
I hereby furnish below particulars of the members of my family who would be eligible to receive widow/
children pension in the event of my death
Name & Address of the family member
Sr . No. Date of Birth Relationship with member
Name Address
1 2 3 4 5
A/304 ARUN APARTMENTS NARAYAN
1 MANISHA KUMARI MHATRE ROAD DAHISAR WEST MUMBAI 7 4 1981 WIFE
400068-400068

A/304 ARUN APARTMENTS NARAYAN

2 MANAS KUMAR MHATRE ROAD DAHISAR WEST MUMBAI 9 8 2009 SON
400068-400068

A/304 ARUN APARTMENTS NARAYAN

3 MANASI KUMARI MHATRE ROAD DAHISAR WEST MUMBAI 22 2 2012 DAUGHTER
400068-400068

* Certified that I have no family, as defined in para 2 (vii) of the Employees' Pension Scheme, 1995 & should
I acquire a family hereafter I shall furnish particulars thereon in the above form.

I hereby nominate the following person for receiving the monthly widow pension (admissible under para
16(2)(a)(i) & (ii) in the event of my death without leaving any eligible family member for receiving pension.
Name & Address of the nominee Date of Birth Relationship with the member
1 2 3

Date : 01-JAN-2021
<<< SIGN HERE

* Strike out whichever is not applicable 3 Signature of thumb impression of the subscriber

CERTIFICATE BY EMPLOYER
Certified that the above declaration & nomination has been signed/ thumb impressed before me by Shri/ Smt.
Kum MANISH KIRAN KUMAR
employed in my establishment after he / she has read the entries / entries have been read over to him / her
by me & got confirmed by him / her
Place
Signature of the employer or other Authorised
Officer of the establishment

Designation
Name & Address of the Factory/ Establishment or Rubber Stamp thereof .

7
 Declaration Form
(To be retained by employer for future reference)

Employees' Provident Fund Organization

THE EMPLOYEES PROVIDENT FUND SCHEME, 1952(Paragraph-34 & 57) &
THE EMPLOYEES PENSION SCHEME, 1995(Paragraph-24)
Declaration by a person taking up employment in the establishment on which Employees
Provident Fund Scheme, 1952 And/Or Employees' Pension Scheme, 1995 is Applicable.
(Please go through the Instrucions)

1 Name Title MANISH

Mr KIRAN
KUMAR

2 Date Of Birth D D M M Y Y Y Y
15 12 1980

3 Father's / Husband's
Mr KIRAN AJAY KUMAR
Name

4 Relationship in respect Father Husband

of above (Please Tick) 

5 Gender Male Female Transender MALE

(Please Tick) 

6 Mobile Number 8889996666

(If Any)

7 Email ID (If Any) manishkumar@gmail.com

8 Whether earlier a member of the Employees' Provident Scheme, 1952?

Yes / No Yes

9 Whether earlier a member of the Employees' Pension Scheme, 1955?

Yes / No Yes
If response to any or both of (8) & (9) above is YES, then MANDATORY fill up the Previous Employement
Details at (10, 11 & 12)
A Previous Employmen Details
10 The details of the Universal Account No (UAN) or Previous PF Member ID
UAN 1234567891
Or
Previous Region Code Office Code Establishment ID Extension Account No
PF Member ID

11 Date of Exit for D D M M Y Y Y Y

Previous Member ID

12 A If Scheme Certificate issued for Previous Employment,

Then Scheme Cretificate No
B If Pension Payment Order (PPO) issued for previous employment,
then PPO No.

8
B Other Details

13 International Worker Yes No

(Please Tick) 

If the reply to (13) above is Yes, then enter details in 13(A), 13(B) & 13(C)

13 A Country of Origin (Please Tick)

Other Than India ( If YES, Please mention

India
Name of the Country)

13 B Passport Number

13 C Passport Valid From D D M M Y Y Y Y

To D D M M Y Y Y Y

14 Educational Illiterate Non Matric Matric Senior Secondary

Graduate
Qualification
Graduate Post Graduate Doctor Technical/Proffessional (Select from drop down)

15 Marital Status Married Unmarried Widow/Widower Divocee 0

16 Specially Abled Yes No If Yes, Tick the Category

(Please Tick) Locomotive Visual Hearing

KYC Document Type Name as on KYC Document Numbers IFSC Code

17 KYC Details
Bank A/c -1*
NPR/Aadhar 123456789012
Permanent Account Number
(PAN) ABCPK1234W
Passport
Driving License
Election Card
Ration Card
ESIC Card
*Mandatory Field (Note: Bank Account Number (Along with IFSC Code)
is MANDATORY. You are however advised to povide all KYC Documents
Available with You in addition to MANDATORY KYCs to avail better Services.
Self-Attested Photocopies of the Documents must be attached with this form.

9
C Undertaking

A I certify that all the information given above is TRUE to the best
of my knowledge & belief.
B In case, earlier a member of EPF Scheme, 1952 and/or EPS, 1955,

(I) I have ensured the correctness of my UAN/Previous PF Member ID

(II) This may also be treated as my request for transfer of funds & service
details if applicable account as declared above to the present PF
Account (The transfer would be possible Identified KYC details
approved by previous employer has been verified by present Employer
using only if the from the previous his Digital Signature Certificate)
(III) I am aware that I can submit my Nomination Form through UAN
Based Member Portal.
Date 4 <<< SIGN HERE
Place Signature of Member

Declaration by Present Employer

A The member Mr./Ms./Mrs. MANISH KIRAN KUMAR has joined on
and has been alloted PF Member ID

B In case the person was earlier not a member of EPF Scheme, 1952 and
EPS, 1995:

1 (POST ALLOTMENT OF UAN) The UAN alloted for the Member is

2 Pls tick the Appropriate Option:

The KYC details of above member in UAN Database

Has not been uploaded

Have been uploaded but not approved
Have been uploaded & approved with DSC

C In case the person was earlier a Member of EPF Scheme, 1952 & EPS, 1955:

1 The above member ID of the member as menioned in (A) above has

been tagged with his/her UAN/Previous Member ID as declared
by Member.

2 Pls tick the Appropriate Option:

The KYC Details of the Above member in the UAN database have been approved
with Digital Signature Certificate & Transfer request has been generated on Portal.

As the DSC of Establishment are not Registered with EPFO, the member has
been informed to file physical calim (FORM-13) for transfer of funds from his
previous establishment.

Date Signature Of Employer with

Seal of Establishment

10
 FORM 'F' THE PAYMENT OF GRATUITY ACT 1972
[See Sub-rule (1) of Rule 6]
NOMINATION

To,

(Give here name or description of the Establishment with full address)

1 . I, Shri / Shrimati / Kumari MANISH KIRAN KUMAR

Whose particulars are given in the statement below ,hereby nominate the person(s) mentioned elow to receive the gratuity
payable after my death as also the gratuity standing to my credit in the event of my death before the amount has become
payable, or having become payable has not been paid &direct that the said amount of gratuity shall be paid in proportion
indicate against the name (s) of the nominees (s)
2 . I hereby certify that the person (s) nominated is a/are members(s)of my family within the meaning of clause (h) of section 2
of the payment of Gratuity Act, 1972.
3 . I hereby declare that I have no family within the meaning of clause (h) of section 2 of the said Act.
4 . (a) My father / Mother / Parents is / are not dependent on me .
(b) My husband's father / Mother / Parents is / are not dependent on my husband .
5 . I have excluded my husband from my family by a notice dated the to the controlling
authority in terms of the proviso the clause (h) of section (2) of the said Act.
6 . Nomination made herein invalidates my previous nomination.

NOMINEE (S)
Proportion by
Name in full with full address Relationship with Age of
which the gratuity
of Nominees(s) the employee nominee
will be shared
(1) (2) (3) (4)
(1) MANISHA KUMARI
A/304 ARUN APARTMENTS NARAYAN MHATRE
ROAD DAHISAR WEST MUMBAI 400068-400068 WIFE 40 100

(2)

>>> SELECT THE NOMINEE FROM DROP DOWN | TOTAL % OF SHARE SHOULD BE 100% <<<

(3)

(4)

so on,

11
 STATEMENT

1 . Name of the emploee in full MANISH KIRAN KUMAR

2 . Sex MALE 3 . Religion HINDUISM
4 . Whether unmarried/married/widow/widower MARRIED

5 . Department / Branch / Section where employed.

6 . Post held with Ticket No . or Serial No., if any 7 . Date of appointment

Vilage Thana Subdivision

Post Office District State MAHARASHTRA
ADDRESS

A/304 ARUN APARTMENTS NARAYAN MHATRE ROAD DAHISAR WEST MUMBAI 400068

Place <<< SIGN HERE

Date 01-JAN-2021 5 Signature / Thumb-Impression of the Employee

DECLARATION BY WITNESSES
Nomination signed / thumb impressed before me .

Name in full and address of witness Signature of witnesses

1. 1.
2. 2.

Place : Date : 01-JAN-2021

CERTIFICATE BY THE EMPLOYER

Certified that the particulars of the above nomination have been verified and recorded in this establishment.
Employer's Reference No., If Any

Name and address of the establishment or rubber stamp thereof

Signature of the employer/office authorised .

Date: 01-JAN-2021 Designation:

ACKNOWLEDGEMENT BY THE EMPLOYEE

Received the duplicate copy of nomination in Form 'F' filed by me and duly certified by the employer.

<<< SIGN HERE

Date : 6 Signature of the Employee
NOTE : Strike out the words and paragraphs not applicable.

12
 Beneficiary Nomination Form
EMPLOYEE NAME :

Relationship % Share of
Name of
to the policy Benefit (Total should add upto
Beneficiary *
holder 100%)

MANISHA KUMARI WIFE 100

EMPLOYEE SIGNATURE : <<< SIGN HERE

(1) NAME MANISH KIRAN KUMAR 7 Signature of the Employee

DATE 01-JAN-2021

For HR use only

Date of receipt of Form:
Received By:
Signature:

PLAN NAME : Kotak Term Grouplan

POLICY NUMBER :
Employee Number :

13
 APPLICATION FOR IDENTITY CARD

Please paste your

passport size
photograph
with white background

PLEASE ENTER THE DETAILS IN CAPITALS

NAME MANISH KUMAR

EMP CODE

BLOOD GROUP B POSITIVE

14
 ACKNOWLEDGEMENT FORM FOR EMPLOYEE SHARE DEALING CODE

Declaration

I acknowledge the receipt of Kotak Mahindra Bank Limited Employee Share Dealing Code and procedures
made thereunder ("the code.") .I have read the code & hereby confirm my understanding & acceptance
of the code .

I am aware that the Bank reserves to itself the right to check with brokerage firms / relevent agencies and
authorities and obtain details of any securities transaction done by me or my affected relative/s. I am also
aware that in such circumstance, if the Bank after checking with brokerage firms / relevent agencies and
authorities finds that securities transaction has been done by me in violation of the Code, the Bank has the
right to take any action against me.

I hereby authorise the Bank or any of its Directors or Officers or seek such information as they deem
necessary from any brokerage firm, stock exchange, clearing house, depository, bank or any other
authority or agency that may be in possession of information relating to any trading activity carried on by
me or by any of my affected relatives. I agree and confirm that any information provided by an organisation
pursuant to the authority hereby granted would not be a breach of confidentiality obligations contained in
any agreement / arrangement between me and such organisation.

<<< SIGN HERE

Signature : 8

Name of Director/ Employee : MANISH KUMAR

Employee Code :

Employee's Designation :

Branch / Department :

Date : 01-JAN-2021

15
Corporate Policy Manual on Conflict of Interest, Conduct, Confidential,
and Proprietary Information and Staff Accountability
MEMORANDUM

This acknowledgement must be Signed and returned to the Human Resources Function, Kotak Mahindra
Bank Ltd., within 10 days.

I have received the Kotak Mahindra Bank policies & procedures regarding conflict of interest, Conduct,
and proprietary information. I have read and agreed to comply with these policies & procedures. I
understand and agree that failure to observe these policies and procedures and such other policies and
procedures as may be in the force from time to time & may subject me to disciplinary action .

Signature : 9 <<< SIGN HERE Date : 01-JAN-2021

Name : MANISH KUMAR

(in block capitals)

Department : Employee No :

For Human Resources Use Only :

Data Entered :

(Signature ,Name,Designation & Date)

Sent to compliance for review :

16
 AGREEMENT TO COMPLY WITH INFORMATION SECURITY GUIDELINES

Each one of us is responsible for ensuring compliance with Kotak’s Information Security Guidelines.

The undersigned confirms that he/she

p has read the relevant Information Security Acceptable Usage Guidelines and understands the
procedures described therein.

p agrees to abide by the guidelines described therein as a condition of continued employment /

contract.

p will attend the Information Security Induction training which is part of corporate induction
programme for all new joiners.

p understands that violators of these guidelines are subject to disciplinary measures including
termination of employement / contract.

p understands that access to the information systems of the company is a privilege which may
be changed or revoked at the sole discretion of the company.

p will promptly report all violations of the information security policies and security incidents
of to aristi@kotak.com

<<< SIGN HERE 01-JAN-2021

11 User's signature Date Location

MANISH KUMAR
User's name in block capital letter Department

01-JAN-2021
Witness name and signature Date

17
 Self Declaration for Medical Fitness

NAME MANISH KUMAR

HAVE YOU EVER SUFFERED FROM THE FOLLOWING - YES / NO

IF YES, DETAILS OF TREATMENT
1) BLOOD PRESSURE No
2) DIABETES No
3) CHOLESTROL No
4) ANY HEART DISEASE No
5) HEPATITIS (LIVER) No
6) RENAL (KIDNEYS) No
7) TUBERCULOSIS No
8) ANY COMMUNICABLE DISEASE No

DECLARATION AND AUTHORIZATION

I, hereby declare that the above information is true and, to the best of my knowledge. I have no illness that will
impede my capacity to perform my duties. I also have no objection to this information being shared by the
Company with it's insurer. I also agree that should the Company so decide, I will subject myself to a medical
examination by a doctor of the Company's choice, whose findings, regarding employment at the Company, will
be binding on me now or anytime later when in employment of the Company.

Signature : 12 <<< SIGN HERE

Name MANISH KIRAN KUMAR
Date : 01-JAN-2021

19
 Form No. 60
[See third proviso to rule 114B]

Form of declaration to be filed by a person who does not have either a permanent
account number or General Index Register Number and who makes payment in
cash in respect of transaction specified in clauses (a) to (h) of rule 11B

1. Full name and address of the declarant MANISH KIRAN KUMAR

A/304 ARUN APARTMENTS NARAYAN MHATRE ROAD DAHISAR WEST MUMBAI 400068-400068

2. Particulars of transaction

3. Amount of the transaction

4. Are you assessed to tax?

5. If yes,

(i) Details of Ward/Circle/Range where the last return of income was filed?

(ii) Reasons for not having permanent account number/General Index Register Number?

6. Details of the document being produced in support of address in column (1)

Verification

I, MANISH KIRAN KUMAR do hereby declare that what is stated above is

true to the best of my knowledge and belief.

Verify today, the 1ST day of JAN 2021

Date: 01-JAN-2021

Place:
<<< SIGN HERE

13 Signature of the declarant

Instructions: Documents which can be produced in support of the address are :-

(a) Ration Card
(b) Passport
(c) Driving licence
(d) Identity Card issued by an institution
(e) Copy of the electricity bill or telephone bill whoing residential address
(f) Any document or communication issued by an authority of Central Government, State Government
or local bodies showing residential address.
(g) Any other documentary evidence in support of his address given in the declaration.

18