Employee Data Form

Name (In Block Gurnani Vineesha Kishore

Letters)

SURNAME FIRST NAME MIDDLE NAME

Father's Name (In

Block Letters)

SURNAME FIRST NAME MIDDLE NAME

Date of Birth 18-10-1997 Female

Gender

Nationality Indian Category

PAN No. BJPPG7083Q Passport No.

UAN 101471793677 Aadhar No. 284594541660

Marital Status Single Blood Group B rhesus positive

Domicile Maharashtra Religion Hinduism

Personal Email ID vineeshag1997@gmail.com Mobile No. 8530025270

Residential Address

Mohan jyot B1-201

Near swami samarth chowk kher section
AMBERNATH-421501
Maharashtra
INDIA

Telephone Number Pincode 421501

Permanent Address

Mohan jyot B1-201

Near swami samarth chowk kher section
AMBERNATH-421501
Maharashtra
INDIA

Telephone Number Pincode 421501

Family Details

Sr No Name of Family Member Dependent Relationship Date Of Birth

for
Mediclaim
(Yes / No)

1 Radhika Gurnani Yes Mother 30-MAY-1972

Academic Details (Begin with last qualification)

Month & Year of Degree / Subject of School / University / % of Marks

Passing Diploma Specialisation College / Board
Institute and
Location

AUG 2018 Bachelor's Commerce University of SMT CHM

Degree (±16 Mumbai COLLEGE
years)

Experience Records (Begin with last employment)

From To Organization Position(s) Held Reason for

Name leaving

MM YY MM YY

12 18 02 21 ICICI Bank Phone Banking FAMILY ISSUE

Officer

01 51 ICICI Bank Phone Banking

Officer
Employment Details of Last Employment

Last Employment (Emp 1) Prior to Last Employment (Emp

2)

Employer Name and full ICICI Bank - ICICI BANK LTD -

address LEXINGTON TOWERS,GHODBUNDER
ROAD THANE WEST

Office Landline Numbers

Job Title / Designation Phone Banking Officer

Gross Salary 18500

Supervisor Name AYUB KHAN

Supervisor Mobile No. AYUBKHAN@ICICIBANK.COM

Reason for Leaving FAMILY ISSUE

Employee Code 404518

HR Contact Name EKTA JAISWAL

HR Contact Email EKTAJAISWAL@ICICIBANK.COM

Reference Details for Professional Reference Checks (Not applicable for Fresher's)

Reference 1 Reference 2

Reference Name AYUB KHAN SHWETA

Reference Designation

Reference Organisation Name ICICI BANK LTD ICICI BANK LTD

Landline Number

Mobile Number 749828159 9323995357

Period for which he/she knows

the candidate

Association with the 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 liability 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.

Do you have any of your relatives working with Kotak Group companies or its subsidiaries? No

If yes, please provide the below details

Name of the person Relationship with Name of the Employee code (if Positio
the person Company available) n

Contact Person (In case of Emergency)

Name Address Tel. Cell Number

Number

Radhika Gurnani Mohan jyot B1-201 8530025270

Near swami samarth chowk
kher section
AMBERNATH-421501
Maharashtra
INDIA

Your Personal Bank Account details (Existing Kotak Bank or any other Bank) *

Name of the Bank Account Number CRN / Customer Beneficiary IFSC Code
Id Name

Vineesha Gurnani 196201509831 VINEESHAG Vineesha ICIC0001962

Gurnani
DECLARATION

I, Vineesha Gurnani hereby declare that all the details furnished by me in this
joining kit (incl. nominee details) and in all documents submitted by me during the process of hiring, are true and
correct to the best of my knowledge and belief. I am fully aware and understand that the Company is entitled to cancel
my candidature and / or withdraw any employment offer made to me at any stage during the selection and offer
process and / or terminate my employment in event any information furnished by me is found to be false/misleading or
incorrect in any manner whatsoever, at the sole discretion of the Company.

In case of changes in any of the details mentioned in the joining kit post submission, I undertake to inform HR in
writing.

1 Signature : Vineesha Gurnani

Date : 16/10/21 Place

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) Vineesha Gurnani

2. Father's/ Husband's Na
3. Date of Birth 18-10-1997 4. Sex Female
5. Marital Status Single 6. Account No 196201509831
(married /unmarried /widow /widower)
7. Address
Permanent Mohan jyot B1-201
Near swami samarth chowk kher section
AMBERNATH-421501
Maharashtra
INDIA
Temporary Mohan jyot B1-201
Near swami samarth chowk kher section
AMBERNATH-421501
Maharashtra
INDIA

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, name &
relationship &
Nominee's
Total amount or address of the
Name of the Address relationship with Date of Birth
share of accumula- guardian who may
Nominees the member tions in Provident receive the amount
Fund to be paid to during the minority of
each nominee nominee

Radhika Gurnani Mother 30-05-1972 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 cancelled.
2 * Certified that my father / mother is / are dependent upon me.

Vineesha Gurnani

* Strike out which ever is not applicable 2 Signature or thumb impression of the subscriber
5
 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

Sr . No. Name & Address of the family member Date of Birth Relationship with
member
Name Address

Radhika Gurnani Mohan jyot B1-201

1 Near swami samarth
chowk kher section
2

* 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

member
Name Address

Radhika Gurnani Mohan jyot B1-201

Near swami samarth chowk
kher section

Date : 16/10/21 Vineesha Gurnani

* 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/ S
Kum Vineesha Gurnani
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 Authorized
Officer of the establishment

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

1 Name Title Vineesha Gurnani

Miss

2 Date Of Birth DD-MM-YYYY

18-10-1997

3 Father's / Husband's name Mr.

4 Relationship in respect of above (Please

Father Husband
Tick)

5 Gender Male Female Transgender

(Please Tick)

6 Mobile Number (If any) 8530025270

7 Email ID (If any) vineeshag1997@gmail.com

8 Whether earlier a member of the Employees' Provident Scheme, 1952? Yes No

9 Whether earlier a member of the Employees' Pension Scheme, 1955? Yes No

If response to any or both of (8) &(9) above is YES, then MANDATORY fill up the Previous Employment Details at
(10, 11 & 12)

A Previous Employment Details

10 The details of the Universal Account No (UAN) Or Previous PF Member ID

UAN 101471793677

Or

Previous PF Region Code Office Code Establishment ID Extension Account No

Member ID MH/BAN/18796/000/404518
11 Date of Exit for Previous Member ID DD-MM-YYYY

12 A. If Scheme Certificate issued for Previous Employment, Then Scheme Certificate No:

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

B Other Details

13 International Worker (Please Tick) Yes No

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
India mention name of the country)

13 B. Passport Number

13 C. Passport Valid From DD-MM-YYYY

Passport Valid to DD-MM-YYYY

14 Educational Qualification

15 Marital Status Married Unmarried Widow/Widower Divorcee

16 Specially Abled (Please Tick) Yes No

If Yes, Tick the Category Locomotive Visual Hearing

17 KYC Details KYC Document Name as on KYC Numbers IFSC Code

Type Document

Bank A/c -1* VINEESHA

KISHORE 196201509831 ICIC0001962
GURNANI

PAN VINEESHA
KISHORE BJPPG7083Q
GURNANI

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 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.

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 16/10/21 Vineesha Gurnani

Place Signature of Member

Declaration by Present Employer

A. The member Mr./Ms./Mrs. ________Vineesha Gurnani_________ has join on _____________________

__________ ______________ and has been allotted 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 allotted for the member is _________________________

2 Please 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, 1995:

1 The above member ID of the member as mention in (A) above has been tagged with his/her

UAN/previous Member ID as declared by Member:

2 Please tick the Appropriate Option

The KYC details of the Above member in 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
claim (FORM-13) for transfer of funds from his previous establishment.

Signature Of Employer with Seal

Date of Establishment
 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 Vineesha Gurnani

Whose particulars are given in the statement below ,hereby nominate the person(s) mentioned below 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)
Radhika Gurnani

Mohan jyot B1-201

Near swami samarth chowk kher section Mother 49 100
(1)
AMBERNATH-421501
Maharashtra
INDIA

(2)

(3)

(4)
 STATEMENT

1. Name of the employee in full Vineesha Gurnani

2. Sex Female 3. Religion Hinduism

4. Whether unmarried/married/widow/widower Single

5. Department / Branch / Section where employed. Branch Banking-VRM

6. Post held with Ticket No. or Serial

No., if any 7. Date of appointment 21-OCT-2021

Village Thana Subdivision

Post Office District State Maharashtra

Place Vineesha Gurnani

Date 16/10/21 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: 16/10/21

 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: 16/10/21 Designation:

ACKNOWLEDGEMENT BY THE EMPLOYEE

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

Vineesha Gurnani

Date : 16/10/21 6 Signature of the Employee

NOTE: Strike out the words and paragraphs not applicable.

 Beneficiary Nomination Form

EMPLOYEE NAME: Vineesha Gurnani

Name of Beneficiary * Relationship to the policy % Share of Benefit (Total

holder should add upto 100%)
Radhika Gurnani Mother 100

EMPLOYEE SIGNATURE:
(1) NAME Vineesha Gurnani SIGNATURE Vineesha DATE 16/10/21
Gurnani

For HR use only

Date of receipt of Form:
Received By:
Signature:

PLAN NAME : Kotak Term Grouplan

POLICY NUMBER :
Employee Number :
 APPLICATION FOR IDENTITY CARD

Paste your
passport size
photograph with white
background

PLEASE ENTER THE DETAILS IN CAPITALS

NAME Vineesha Gurnani

EMP CODE
BLOOD GROUP B rhesus positive
 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.

Signature : Vineesha Gurnani

Name of Director/ Employee : Vineesha Gurnani

Employee's Designation : Phone Banking Officer

Branch / Department : Branch Banking-VRM

Date : 16/10/21
 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 Vineesha Gurnani Date 16/10/21

:

Name Vineesha Gurnani

Department Branch Banking-VRM

For Human Resources Use Only:

Data Entered

Sent to compliance for review

 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

 has read the relevant Information Security Acceptable Usage Guidelines and
understands the procedures described therein.
 agrees to abide by the guidelines described therein as a condition of continued employment
/ contract.
 will attend the Information Security Induction training which is part of corporate induction
programme for all new joiners.
 understands that violators of these guidelines are subject to disciplinary measures
including termination of employement / contract.
 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.
 will promptly report all violations of the information security policies and security incidents
of to aristi@kotak.com.

User's signature Vineesha Gurnani Date 16/10/21

User's name in block capital letter Vineesha Gurnani Department Branch

Banking-VRM

Witness name and signature Date

 Self Declaration for Medical Fitness

Name: Vineesha Gurnani

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: Vineesha Gurnani

Name: Vineesha Gurnani

Date: 16/10/21