Form No. 11 (New) Declaration Form (To be retained by the Employer for Future reference) Employees’ Provident Fund Organization ‘THE EMPLOYEES’ PROVIDENT FUNDS SCHEME, 1952 (PARAGRAPH-34 & 57) & ‘THE EMPLOYEES’ PENSION SCHEME, 1995 (PARAGRAPH-24) DECLARATION BY A PERSON TAKING UP EMPLOYMENT IAN ESTABLISHMENT ON WKICH EMPLOYEES’ PROVIDENT FUND SCHEME 1952 aNo/OR EMPLOYEES’ Pension SCHEME, 1995 6 APPLICABLE. (PLEASE GO THROUGH THE INSTRUCTIONS) 1) nome oti) _ WI SAlAlT | [Pll Ofe! [evs [as] (lease Tek 2) ate of ith oom [ul y[y[y[y o[9] 4/2 }afslolé aromersy ome (ETRE TMEET [Malelab [Alm] [Plo [ely Husbone’s Nome 4) Relationship in espectof(3) above father sasband (lease Tk) = 5) Gender vale | Female [Transgender (Please Tick) Tail 6) Mobite Number 718 [ols [3]41213]2| (aay) PAT NIOTETyIvis]elAlr| 2{2l@lalmiAlTiL| «| ¢ fo [ny 7) Email id (If Any) 8) Whether earlier a member of THE EMPLOYEE'S PROVIDENT FUND SCHEME, 1952? (Please Tick) yes No. NVEE'S PENSION SCHEME, 1995? ves 6 No 9) Whether earlier a member of THE EMPLO} {Please Tick) IF RESPONSE-TO ANY OR BOTH OF (8) & (9) ABOVE IS VES, THEN MANDATORILY FILL UPTHE PREVIOUS EMPLOYMENT DETAILS AT (10,118 12): Page 1 of3‘A. Previous Employment Details 10) The details of the Universal Account Number (UAN) or Previous PF Member ID: Uae [oie Osea orgies] 3S S| Heya eager] OW pia Onan eg alg or Previous PF member ID | Region code | Office Code | Establishment 0 [Extension] Account Number 11) Date of exit for previous D D ™ ¥_[yY_[_¥ Y Member 1D (OD/Mm/v¥YY) a Cote tetole2 lz 12) (A) If scheme certificate issued for previous employment, Then scheme certificate number: (8) f pension payment order (PPO) issued for previous employment, Then PPO number: B. Other Details 13) International Worker Yes, NO (Please Tick) we 13(A) Country of origin (Please Tick) aa Other than India (if yes, please menction name of the country) — 13(8) Passport Number 13(C) Passport valid from [>] 0 [mM] M[V[¥]v[¥ To o[o[m[m[¥]y[y]yv SENIOR | GRADUAT] POST TECHNICAL] 14) Educational | iwuiTeraTe [Non -Mmarric|_matric_|seconoa| _& | GRaouar| voctor | proressionat Qualification — (Please Tick) 15) Marital Status [Married _[_ Unmarried Widow Divoreee (Please Tick) = 16) Specially Abled YES: NO TFYES, TICK THE CATEGORY (Please Tick) es LOCOMOTIVE] VISUAL__[_HEARING Page 2 of 317) KYC Details KYC Document Type. ‘Name as on KYC Document Number kemarks Bank A/e-1* WI RAT PANDEY |50400U06FT: 4957 LWOFCI0003 543) 6 dt NNPR/ Aadhaar JER AT PANDEY 177717124 63693 Permanent account VT ROT DAWLEY ICV PP 34.63 Number (PAN) Passport Driving licence Election Card, Ration Card ESIC Card 3 * Mandatory Field (Note : Bank Account Number (Along with IFSC code) is Mandatory. You are however advised to provide 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 . Undertaking: A. I CERTIFY THAT ALL THE INFORMATION GIVEN ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE AND BEHALF BB. IN CASE, EARLIER A MEMBER OF EPF SCHEME, 1952 AND / OR EPD, 1995, (I) THAVE ENSURED THE CORRECTNESS OF MY UAN / PREVIOUS PF MEMBER ID. {ll) THIS MAY ALSO BE TREATED AS MY REQUEST FOR TRANSFER OF FUNDS AND SERVICE DETAILS IF APPLICABLE FROM THE PREVIOUS ACCOUNT AS DECLARED ABOVE TO THE PRESENT P.F ACCOUNT. (THE TRANSFER WOULD BE POSSIBLE ONLY IF ‘THE IDENTIFIED KYC DETAILS APPROVED BY PREVIOUS EMPLOYER HAS BEEN VERIFIED BY PRESENT EMPLOYER USING HIS DIGITAL SIGNATURE CERTIFICATE). (itl) AM AWARE THAT | CAN SUBMIT MY NOMINATION FORM THROUGH UAN MEMBER PORTAL. pate: 24/06 (2022 irra Pomdey Place: MUMGAL Mgnature of Member DECLARATION BY PRESENT EMPLOYER .HAS JOINED ON AND HAS BEEN ALLOTTED A. THE MWMBER MR./MS./MRS. PF MEMBER ID : B._ INCASE THE PERSON WAS EARLIER NOT A MEMBER OF EPF SCHEME, 1952 AND EPS,1995: + (POST ALLOTEMENT OF UAN ) THE UAN ALLOTTED FOR THE MEMBER IS wn + PLEASE TICK THE APPROPRIATE OPTION: THE KYC DETAILS OF HE ABOVE MEMBER IN THE UAN DATA BASE. HAVE NOT BEEN UPLOADED HAVE BEEN UPLOADED BUT NOT APPROVED HAVE BEEN UPLOADED APPROVED WITH DSC C._ INCASE THE PERSON WAS EARLIER A MEMBER OF EPF SCHEME, 1952 AND EPS,1995: 0 Tne ABOVE MEMBER ID OF THE MEMBER AS MENTIONED IN (A) ABOVE HAS BEEN TAGGED WITH HiS/tHER UAN / PREVIOUS MEMBER ID AS DECLARED BY MEMBER * PLEASE TICK THE APPROPRIATE OPTION:- FAS eye OETALS OFTHE ABOVE MEMOER INTHE UAN DATABASE HAVE BEEN APPROVED WITH DIGITAL SIGNATURE CERTFICATE AND TRANSFER REQUEST HAS BEEN GENERATED ON PORTAL. [aS THE DSC OF ESTABLISHMENT ARE NOT REGISTRED WITH EPFO, THE MEMBER HAS BEEN INFORMED TO FILE PHYSICAL CLAIM (FORM - 13) FOR TRANSFER OF FUNDS FROM HIS PRIVIOUS ESTABLISHMENT mee SIGNATURE OF EMPLOYER WITH SEAL OF ESTABLISHMENT