Employee Joining Form

Personal Information
Full Name Name as per AADHAAR
(as per Aadhaar) - (First / Middle / Last)
Gender (Gender Details) Select Marital Status: Married Unmarried Widowed

Date of Birth Date Of Birth

dd/month/yyyy - e.g., 06/June/2020
Date of Joining Actual Date Of Joining
dd/month/yyyy - e.g., 06/June/2020
Candidate ID Complete alpha-numaric candidate id e.g - "CANDIDATE-3-01234"
Nationality Please mention all the country names if you have multiple citizenship
e.g - India /India and US

Email Address (personal) Personal email ID

Mobile Number (personal) Personal Mobile number
Present Home Address
Present Home Address

Same as present home address

Permanent Home Address
Permanent Home Address

Father's Full Name Father’s Name

Mother's Full Name Mother’s Name
Husband's Full Name (where applicable) Husband’s Name (For Female employees if married)
DXC Job Title Job Title/Designation as per Offer Letter

Government Identifiers / ID Proof Details

Aadhaar Number AADHAAR Number
PAN (Permanent Account Number) PAN Number
Driver's License / Passport / Voter ID Driver's License / Passport / Voter ID

Emergency Contact Details

Primary Emergency Contact Please provide 2 different emergency contact details
Full Name Name of the emergency contact
Relationship (e.g. Mother/Father/Friend Emergency contact’s relationship with you
etc.)
Home Address Emergency contact’s home address
Mobile Number Emergency contact’s Mobile Number
Email ID (if known) Emergency contact’s email ID if available
Secondary Emergency Contact
Full Name Name of the emergency contact
Relationship (e.g. Mother/Father/Friend Emergency contact’s relationship with you
etc.)
Home Address Emergency contact’s home address
Mobile Number Emergency contact’s Mobile Number
Email ID (if known) Emergency contact’s email ID if available
 Nomination Details for Gratuity / Provident Fund / Pension
Nominee 1 Details Nominee can be Spouse, Children, Parents
Full Name of Nominee Name Of the Nominee
Address of Nominee/s Address of the Nominee

Relationship with Employee Nominee's relationship with you

Date of Birth of Nominee
dd/month/yyyy - e.g., 06/June/2020
Age of Nominee
Proportion of Share
Enter Percentage if there is more than one
nominee - e.g., 100%, 50%
Date Of Birth of the Nominee
Age of the nominee
Single Nominee - 100%,
multiple nominees - distribute the
percentage sum should be 100%

If the nominee is a minor, name, Guardian Name: If the nominee is minor, please provide
the guardian details. Guardian cannot be You.
relationship and address of the guardian
who may receive the amount during the Guardian Address:
minority of nominee Guardian Relationship:
Nominee 2 Details (this is optional only if
you wish to split the nomination)
Full Name of Nominee
Address of Nominee/s

Relationship with Employee Select

Date of Birth of Nominee
dd/month/yyyy - e.g., 06/June/2020
Age of Nominee
Proportion of Share
Enter Percentage if there is more than one
nominee - e.g., 100%, 50%
If the nominee is a minor, name, Guardian Name:
relationship and address of the guardian
Guardian Address:
who may receive the amount during the
minority of nominee Guardian Relationship:
Nominee 3 Details (this is optional only if
you wish to split the nomination)
Full Name of Nominee
Address of Nominee/s

Relationship with Employee Select

Date of Birth of Nominee
dd/month/yyyy - e.g., 06/June/2020
Age of Nominee
Proportion of Share
Enter Percentage if there is more than one
nominee - e.g., 100%, 50%
If the nominee is a minor, name, Guardian Name:
relationship and address of the guardian
Guardian Address:
who may receive the amount during the
minority of nominee Guardian Relationship:

I, the undersigned, hereby certify and confirm that the information provided above are true to the best of my
knowledge and have reported to work on the above date.
Place Joining Location
Date Form Filling Date
Signature of Employee Insert your Signature
 Employee Undertaking

Name: Name as per AADHAAR

Candidate ID: Complete alpha-numaric candidate id e.g - "CANDIDATE-3-01234"

Date: Actual Date Of Joining

I. CONFIDENTIALITY

A. NON-DISCLOSURE

Employee will treat as confidential any information, conveyed or otherwise coming to the knowledge of the Employee by virtue
of his employment by Xchanging Technology Services India Private Ltd., a DXC Technology Company (“hereinafter referred
to as Company” which shall include all affiliates, subsidiaries and group companies) and will not disclose any such information
to any third party including but not limited to the media, competitors, friends, family, future employer and any other third party,
nor to any employees of the Company who do not have a business need to know this information for the purpose of performing
their duties as employees of the Company during the period of employment or any time thereafter. The following information
(hereinafter “Confidential Information”) is specifically covered by the confidentiality provisions herein:

1) Any and all information relating to the design, architecture, flowcharts, source or object code and documentation of any and all
computer software products which the Company has developed, acquired or licensed or is in the process of developing, acquiring
or licensing or shall develop acquire or license in the future. Employee is aware that such information including all copies
thereof are the property of the Company and shall not be copied or removed by any means outside the premises of the Company
and that such information is valuable, confidential and is to be treated as a trade secret.

2) Any and all information relating to the Company policy (the term ‘Company Policy’ shall mean the applicable DXC Policy as
detailed in DXC’s intranet), procedures, know-how, trade secrets, methods and approaches.

3) Any and all information relating to the employment, job responsibility, performance, salary and compensation of any Employee
or officer(s) of the Company.

4) Any and all information and data relating to or belonging to the Company, its affiliates, licensees, customers, subcontractors,
suppliers, vendors (including the affiliates officers and employees of any of the above and their customers) to which Employee
may obtain access.

5) Any other information that is marked “confidential” or otherwise would be treated as confidential by a prudent person operating
in an international IT environment.

B. INFORMATION SECURITY

1) Employee hereby understands and agrees that security of the Company, its affiliates and customers, relies on the awareness,
knowledge, co-operation and diligence of every individual. Strict compliance with general policy and specific security directives
of the Company, its affiliates and customers is mandatory and Employee agrees to strictly observe all such current and future
security policies and directives.

2) Employee agrees and undertakes that Employee will not share, disclose or transmit any Confidential Information with any third
party other than as permitted herein.

3) It is Employee’s job responsibility to maintain a secure information-processing environment.

4) Employee is bound by all the terms of this Agreement outside the premises of the Company and outside normal working hours.
II. COMPLIANCE WITH US LAWS

A. Employee acknowledges and understands that any equipment and/or technical data/information and/ or services related to
U.S.-origin technologies covered by either the U.S. Commerce Control List (CCL) or the U.S. Munitions List (USML), and
belonging to the Company or any of its affiliates or any customer or client of the Company or any of such customer’s or client’s
affiliates or subsidiaries, to which Employee may have access or which may be disclosed to Employee either in the course of
employment with the Company or while working for the Company as a subcontractor, consultant, supplier/vendor or in any other
independent status, is subject to the Export Administration Regulations (Title 15 Code of Federal Regulations, Parts 730 – 774)
and/or the International Traffic In Arms Regulations (Title 22 Code of Federal Regulations, Parts 120 – 130), respectively.

B. Employee hereby certifies that such equipment, technical data/information and/or services will not be further disclosed,
exported, re-exported or transferred by Employee in any manner to any other foreign national or any foreign country without prior
written approval of the Company and/or the U.S. Commerce Department’s Bureau of Industry and Security (BIS), and/or the U.S. State
Department’s Directorate of Defense Trade Controls (DDTC), as required and will be in compliance with the applicable U.S. laws and
regulations.

III. OWNERSHIP IN WORK

During employment with the Company, the Employee may perform services related to computer software systems and related
material.
All work produced by the Employee and done for the Company including software writing or development during employment
with the Company shall be work done for and of the ownership of the Company and shall be the property of the Company. The
Employee understands and declares that Employee shall not claim any ownership therein or claim to be the author thereof.
Employee agrees that the work product of these efforts shall be “works made for hire” belonging to the Company in which
Employee retains no right, title or interest. Furthermore, Employee hereby assigns any and all rights in such work product to the
Company and herewith specifically waives any moral rights as may accrue in such work product.

IV. COPYRIGHT

In performing the work assigned to Employee, Employee will not use any third party information, including but not limited to
information which Employee agreed to maintain or was obligated to maintain as confidential, and will not copy any material of
a third party which bears a notice of copyright or similar proprietary notice.

V. CODE OF ETHICS

A) Employee certifies that Employee has read the Company Code of Ethical Business Conduct and understands that this
Code represents the Policies of the Company as well as its subsidiaries and affiliates worldwide.

B) Employee also certifies that neither Employee, nor, to Employee’s knowledge, any member of Employee’s
immediate family is engaged, or since the date Employee has been engaged, directly or indirectly, in any activity which creates
a conflict of interest which is or may be adverse to the best interests of the Company or any of its affiliates.

C) Employee further certifies that Employee will immediately disclose any situation in the future that may possibly be
interpreted as involving a conflict of interest or any other violation of the Company Code of Ethical Business Conduct.

VI. NON-COMPETE

Employee expressly undertakes and agrees that for a period expiring 12 [twelve] months after cessation of employment with
the Company for whatever reason, Employee will not:
a. be engaged (by way of employment, consultancy or partnership) either directly or indirectly by a customer of the Company
(or any affiliate thereof) on whose account the Employee has worked in 12 months prior to his departure;
b. work on any product similar to the product of the Company on which Company has intellectual property rights that the
employee has worked in the 12 months prior to his departure.
 VII. DURATION OF OBLIGATION

This Agreement is intended to and will continue beyond the effective duration of the employment relationship between the parties.
Repudiation of the contract shall not discharge any of such obligations.

VIII. CHANGE IN POLICIES ETC.

To preserve the Company’s ability to meet its needs under changing conditions, Company may modify, augment, delete, or revoke
any and all policies, procedures, practices, or statements regarding my employment at any time and without notice. Any such
changes will be effective immediately upon approval by an officer of the Company or by official declaration through email to all
employees, unless otherwise stated.

IX. NOTICE PERIOD:

The Employee and/or Company is bound, at all times to give the notice in accordance with the Company Policy in case of cessation of
service for any reason, other than, dismissal from service by Company on disciplinary grounds.

X. SEVERABILITY

If any provision of this Agreement is held invalid or unenforceable by a court or competent jurisdiction, it shall be considered severed
from this Agreement, it shall be deemed automatically replaced by an alternative provision coming closest in scope and mended effect to
the original provision, and it shall not invalidate the remaining provisions contained herein which shall continue in full force and effect.

XI. DISCLOSURE OF CONFIDENTIALITY/NON-COMPETE AGREEMENTS

Employee represents and warrants that, except as is written above, he/she has no employment, confidentiality, non-disclosure, non-
solicitation or non-competition agreements with or obligation to others, nor does Employee have any agreements or obligations that
might conflict with this Agreement. Employee further represents and warrants that to the extent that he/she has knowledge of any
other person or entity’s confidential or proprietary information through his/her prior employment, Employee will not disclose, share,
copy or otherwise make any use of such confidential or proprietary information in connection with Employee’s work for the Company.

Employee further acknowledges and agrees that to the extent that any provision in this Agreement conflicts with any other agreement
entered into between the Company and Employee and signed by Employee covering any of the matters set forth in this Agreement, the
terms of the last signed agreement shall control.

By signing this document, I acknowledge the statements above, as part of the terms and conditions of employment with the Company.

Signature: Date:

Insert your signature here Actual Date Of Joining

Employee Declaration

Name: Name as per AADHAAR

Candidate ID: Complete alpha-numaric candidate id e.g - "CANDIDATE-3-01234"

Date: Actual Date Of Joining

I hereby declare that I have resigned from my previous employment (where previously employed). By signing below, I am
acknowledging that if any action is taken against me by my former employers, I shall be fully responsible for the same and the
Company shall not be held responsible for any action taken by my previous employers on me at any time in the future.

By signing this document, I acknowledge the statements above, as part of the terms and conditions of employment with the Company

Signature: Insert your signature here Date:

Actual Date Of Joining
Data Protection Compliance Briefing for Staff Providing Offshore Support to EU Companies

Name: Name as per AADHAAR

Candidate ID: Complete alpha-numaric candidate id e.g - "CANDIDATE-3-01234"

Date: Actual Date Of Joining

What is European Data Protection all about?

The expansion of computer technology, and in particular the Internet, over the past three decades reinforced international concern
regarding the ease with which data could be transmitted and accessed globally. This led to several governments, across the world,
adopting privacy guidelines or introducing privacy legislation, intended to protect individuals from unnecessary and excessive
collection and potential misuse of their personal information.

During the 1970's and 80's, several European countries had introduced differing legislation to protect privacy and personal information,
which, by the early 1990's, because of major variations in the respective countries law, had begun to prevent the free movement of
information across the European Union ("EU"). Together with the concern for easy global accessibility of personal information, it was
clear that cohesive, EU-wide data protection regulations were fundamental to protecting its citizen's privacy whilst encouraging the
principle of a "Single European Market".

The result was the adoption by the EU of the European Union Directive on Data Protection (Directive 95/46/EC) ("the Directive"),
which has been adopted and implemented by every EU Member State with varying interpretations and compliance requirements.

Iceland, Liechtenstein and Norway are not members of the EU but as members of the European Economic Area ("EEA") they have
adopted comparable legislation.

Why does the Directive affect Company companies located outside of the EU?

The Directive imposes strict obligations on EU Companies who collect and process personal information to conduct their business
activities; obligations which extend to employees who use that information in the course of their work and any other persons or
companies providing business support. It also gives individuals, which includes employees, rights with regard to the use and disclosure
of their information.

Companies who process personal information must apply eight data protection principles to that processing. Failure to apply these
principles will leave them open to prosecution.

In addition, each EU Member State has appointed a Data Protection governing body; in most cases the governing body is responsible
for providing guidance on interpretation and how the Directive should be applied to the processing of personal information. Companies
entities located in the EU must have regard to the Eight Principles and guidance material or codes of practice issued by the governing
bodies whenever they processes personal data for their own business purposes; Company clients located in the EU must also comply
and have a duty to ensure that Company processes their information in accordance with the Directive.

Of the Eight Principles, there are two that must be applied by EU companies that transfer personal information to countries outside of
the EEA: the Seventh Principle relates to the security of personal information and Eighth Principle relates to transfers of personal
information to countries outside of the EEA. Although the other six principles must still be adhered to, their application to transferred
personal data will very much depend upon the type of processing that would be carried out after transfer; compliance with the other
six principles will normally be managed through written agreement, process and procedure. This briefing concentrates on the Seventh
("Security") and Eighth ("Transfer") Principles.
The Security Principle states:

"Member States shall provide that [Company] must implement appropriate technical and organizational measures to protect personal
data against accidental or unlawful destruction or accidental loss and against unauthorized alteration, disclosure or access, in particular
where processing involves the transmission of data over a network, and against all other unlawful forms of processing. Having regards
for the state of the art and the costs of their implementation, such measures shall ensure a level of security appropriate to the risks
represented by the processing and the nature of the data to be processed".

The Security Principle requires [Company] to look at security provisions at every point of the processing. We must consider security
not simply as a technology-related matter but as a whole way of managing and operating with people, facilities and other agencies. In
addition to implementing adequate system and organizational security, [Company] is required to determine the integrity and reliability
of staff that will have access to personal information.
This Principle places responsibilities on EU companies to ensure all persons and companies that have access to and process personal
information will apply and adhere to security measures that are put in place to protect the information and the individuals to whom it
relates. It requires companies and organizations to ensure that all employees that have access to personal information are aware of data
protection law and their personal responsibilities under the law.

Data Protection Regulatory Authorities have indicated that companies should have due regard for the international security standard
ISO27001/02 when considering what security measures should be taken to protect personal information.

The Transfer Principle states:

"Member States shall provide that the transfer to a third country of personal data which are undergoing processing or are intended for
processing after transfer may take place only if, without prejudice to compliance with the national provisions adopted pursuant to the
other provisions of the Directive, the third country in question ensures an adequate level of protection.

The adequacy of the level of protection afforded by a third country shall be assessed in the light of all the circumstances surrounding
a data transfer operation or set of data transfer operations; particular consideration shall be given to the nature of the data, the purpose
and duration of the proposed processing operation or operations, the country of origin and country of final destination, the rules of law,
both general and sectoral, in force in the third country in question and the professional rules and security measures which are complied
with in those countries."

In plain language, this means that transfers outside of the EEA are prohibited unless the exporting company ensures there is an adequate
level of protection for the rights and freedoms of individuals in relation to the processing of their personal data in the receiving country.
The European Commission has already determined that the following countries do provide an adequate level of protection:
Switzerland, Canada, Argentina, Isle of Man, Baliwick of Guernsey, Jersey, Faroe Islands. This determination means that the Transfer
Principle does not apply if personal information is transferred and processed in these countries A transfer is the transmission of personal
information to countries outside the EEA, or accessing personal data remotely from outside the EEA. The Directive includes provision
to stop transfers of personal information to countries, which it considers do not provide adequate protection for the rights and freedoms
of individuals in relation to the processing of their information.

It is a simple mistake to believe that because there is no tangible evidence of processing of information - no data input, no paper copies,
no files, etc, there is no transfer and you do not need to concern yourself with this Principle. However, every possible means of
disseminating information has been included in the Directive's definition of processing, including merely reading the information on
screen.

The determination of adequacy requires [Company ] to consider whether:

• The destination country has privacy laws and if so whether the law is applied;
• The destination country has any industry codes of practice applicable to the processing;
• any company policies or procedures apply to the processing;
• any legal, company or contractual redress available to the data subjects, and
• the political environment is stable

EU Member States have recognized that certain "standard" contractual clauses, approved by the European Commission will provide
adequacy and Company’s entity located in the EU use these standard clauses. However, the use of the clauses does not override the
above considerations and a transfer can be prohibited if, for example, the security of the processing is threatened by political instability.
Key to achieving adequacy is the requirement to first ensure that the receiving company's processing location has the resources and
organizational structure to implement security measures. This is typically achieved by a security due diligence assessment of the
receiving company and environment.

How does the Directive affect the way you work?

If your work involves you providing support to companies entities located in the EU, for example, providing mainframe support,
remotely accessing applications that hold EU personal information to rectify faults or providing help desk support, you will have
access to EU personal information in order to complete your work, or you will have potential access to personal data that you are not
authorised to process/view.

If, for whatever reason, you are authorised to access personal information, you have a fundamental duty of confidentiality with respect
to that information. In addition, the Directive requires Company to ensure you process that information fairly and correctly. You cannot
misuse personal information or use it for your own reasons, even if you believe they are well intentioned. Any unauthorized access to
personal data will be a breach of EU law.

What can you do to comply with data protection obligations?

By adopting the following measures, you can ensure your working practices help you comply with your data protection responsibilities
in respect to Company and Company client's personal information.

• Be aware of and understand what your contractual responsibilities are.

• Be aware of Company data protection and security policies and your responsibilities therein.
• Keep personal information entrusted to you confidential and secure.
• Never disclose personal information in any form without the proper authorization. Know whom you are dealing with. If you are
asked to disclose or transfer personal data always verify the identity of the person making the request and ensure that they are
entitled to have it. Never make assumptions, even if the person claims to be a manager or relative. If in doubt, refuse politely and
explain why you are unable to provide them with the information right away and ask them to put their request in writing, or refer
them to your Manager.
• Be aware of people overlooking your screen and always activate your screen saver when you are away from your desk.
• Never share your access passwords or exceed your access rights.
• Do not duplicate, and retain locally, personal information held on systems to which you have access.
• Follow correct procedures and encourage others to do the same.
• Only process Company, Company’s client's and the client’s customer's personal information for the purposes specified in the
contract, either between each Company entity and/or Company and the client.

Consequences of non-compliance
Companies EU entities failure to comply with the Seventh and Eighth Principles can be subject to enforcement measures and
prosecution under the law, which may result in fines, custodial sentences and orders to stop processing. Individual employees may
also be liable under the law and will almost certainly be subject to internal disciplinary procedures.

The potential damage to a Company client's reputation and potential loss of that business for Company would be significant. Needless
to say, the potential damage to Company’s reputation if it is successfully prosecuted for a breach of data protection and/or security
could be considerable. With the continued growth in offshoring, it is vital that Companies entities outside of the EU understand and
fully support the restrictions imposed by the Directive and work with the EU companies to achieve compliance. Every employee
providing support to an EU company is a key part of that compliance and has personal responsibility for adhering to the contractual
obligations and related company policies.

Company’s Code of Ethics and Standards of Conduct considers non-compliance with Company policy, rules and procedures as gross
misconduct, which may result in dismissal. By signing this document, I acknowledge that I have read and understood the contents of
this Company’s Data Protection Awareness briefing and do undertake to abide by the same. I also understand that during the term of
my employment and thereafter I shall be expected to maintain the confidentiality of the information received during my tenure with
this organization and therefore do hereby reaffirm my commitment to maintain the confidentiality of any information received.

Signature: Date: Actual Date Of Joining

Insert your signature here
Ethics and Integrity

Name: Name as per AADHAAR

Candidate ID:
Complete alpha-numaric candidate id e.g - "CANDIDATE-3-01234"
Date: Actual Date Of Joining

As you begin your employment with Company, you are invited to learn more about Company's strong culture of integrity. At Company,
how we operate is as important as what we achieve; performance and integrity go hand in hand. We believe that with commitment to
performance and integrity, Company's strong reputation among colleagues, clients, and business partners is rightfully earned and assured.

Company is a respected global corporation and every employee's ethical and professional business conduct is vital to our continued
success. At Company, we work hard to sustain a culture that is positive, open, honest, and unites us around common, well-understood
corporate values and standards of business conduct.
The Ethics and Compliance Office (ECO) is in place to help promote an organizational culture that encourages ethical conduct and a
commitment to comply with Company's Code of Business Conduct, our internal company policies and the law. The ECO is a dedicated
resource for employees seeking ethics/compliance guidance or more information about any of the following topics:
• Company's Code of Business Conduct
• Company Policy
• Code of Business Conduct training
• Company Open Line, Company's confidential ethics and compliance advice and reporting hotline

As part of your onboarding process, you are required to complete the following items that relate to integrity and ethical business
conduct:
1.Acknowledge that you've received and read Company’s Code of Business Conduct, including the CLEAR Values
2.Acknowledge that you've received and read Company's most recent Code of Business Conduct Training

Speak Up and Make a Difference

Each of us is responsible to report known or suspected ethical and/or legal misconduct, including violations of
the Code, noncompliance with Company policy, and violations of the law in any jurisdiction where Company
operates. The following channels are available for ethical advice or reporting misconduct:
• Your local supervisor or manager
• Your department or function head
• Your local human resources manager, or an HR representative at a higher level
• The Ethics and Compliance Office at SpeakUp@dxc.com
• The Company Open Line - DXC’s always available, confidential, anonymous, toll-free and web-enabled advice and
reporting channel at https://secure.ethicspoint.com/domain/media/en/gui/32161/index.html
Company’s policy forbids retaliation of any kind, either direct or indirect, toward any employee who in good faith uses the
Open Line or any other reporting method to raise compliance and ethics-related issues, or to question any other employee's
professional or personal conduct.
Learn More and Stay Informed. Bookmark the following resources for future reference:
• Link to Company's Code of Business Conduct -
https://assets1.dxc.technology/governance/downloads/DXC_Code_of_Conduct.pdf
• Link to Company Human Resources Policies https://dxc.policytech.com/
By signing this document, I acknowledge that I have read and agree to comply with the Company’s Code of Business Conduct and the
Clear Values. In addition, I acknowledge that I have read the materials presented in the Code of Business Conduct training document. I
understand that any questions I have about the Code of Business Conduct should be directed to my manager or the Company’s Ethics
and Compliance Office. I pledge to perform with integrity through my employment with the company and adhere to Company's Code of
Business Conduct.

Thank you for taking the first step in understanding and committing to Company's culture of integrity. We are all responsible for the
consequences of our actions, and compliance with the Code of Business Conduct is key to a successful career at Company.

Signature: Date:

Insert your signature here Actual Date Of Joining

 Payment of Gratuity (Central) Rules
FORM 'F'
See sub-rule (1) of Rule 6

Nomination

To,
(Give here name or description of the establishment with full address)
Legal Entity Name and Registered Office Address (Legal Entity Name available at the bottom of 1st page in Offer Letter)

I, Shri/Shrimati/Kumari Name as per AADHAAR

(Name in full here)
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 that amount has become payable, or having become payable has not been paid and direct that the
said amount of gratuity shall be paid in proportion indicated against the name(s) of the nominee(s).
2. I hereby certify that the person(s) mentioned is/are a member(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 to clause (h) of Section 2 of the said Act.
6. Nomination made herein invalidates my previous nomination.

Nominee(s)

Name in full with full Relationship with Age of Proportion by which

address of nominee(s) the employee nominee the gratuity will be
shared

(1) (2) (3) (4)

1. Nominee can be Spouse, Children, Parents Nominne's relationship

with you
Nominee's
age
Single Nominee - 100%,
multiple nominees - distribute the
percentage and sum should come
2. Nominee's address is manadatory up to 100%

3.
So
on.
 Statement
1. Name of employee in full Name as per AADHAAR

2. Sex Gender Details

3. Religion Religion details

4. Whether unmarried/married/widow/widower Marital Status

5. Department/Branch/Section where employed Legal Entity Name available at the bottom of 1st page in Offer Letter

6. Post held with Ticket No. or Serial No., if any Designation as per your Offer Letter
7. Date of appointment Actual Date Of Joining

8. Permanent address: Permanent Home Address

Village Thana Sub-division
Post Office District State

Joining Location Insert your signature here

Place:
Signature/Thumb-impression of the
Employee
Form Filling Date
Date:

Declaration by Witnesses

Nomination signed/thumb-impressed before me

Name in full and full address of witnesses. Signature of Witnesses.
1. 1.

2. 2.

Place: Joining Location

Date: Form Filling Date

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 Signature of the employer/Officer authorised
Designation

Date: Name and address of the establishment or

rubber stamp thereof.
 Acknowledgement by the Employee

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

Place your signature here

Form Filling Date
Date: Signature of the Employee

Note.—Strike out the words/paragraphs not applicable.

 FORM 2 (Revised)

NOMINATION AND DECLARATION FORM FOR UNEXEMPTED/

EXEMPTED ESTABLISHMENTS

Declaration and Nomination Form under the Employees’ Provident Funds and
Employees’ Pension Scheme

(Paragraphs 33 & 61 (1) of the Employees Provident Fund Scheme, 1952 and Paragraph 18 of the Employees’ Pension scheme, 1995)

1. Name (in Block letters) : Name in Block Letters as per AADHAAR

2. Father’s/Husband’s Name : Father's/Husband's Name

3. Date of Birth : Date Of Birth as per AADHAAR

4. Sex : Gender Details

5. Marital Status : Marital Status

6. Account No. : Leave it blank - Do Not Mention any account details

7. Address Permanent : Permanent Home Address

Temporary : Temporary Home Address

8. Date of joining : Actual Date Of Joining

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

Name of
nominee/ Address Nominee’s relation- Date of Total amount of share of If the nominee is a minor,
nominees ship with the member Birth Accumulations in Provi- name & relationship & address
dent Fund to be paid to of the guardian who may
each nominee receive the amount during
the minority of nominee

1 2 3 4 5 6

Date of birth If the nominee is minor, please provide

Nominee's Single Nominee - 100%, the guardian details. Gaurdian cannot be
Address of the relationship of the nominee multiple nominees - distribute the
Nominee can be You.
Spouse, Children, Parents Nominee with you percentage sum should be 100%

1 * Certified that I have no family as defined in para 2(g) of the Employees’ 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.

Insert your signature here

Signature or thumb impression of the subscriber

*Strike out whichever is not applicable.

 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.

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

1 2 3 4 5

1 Spouse, Children Details if Married

Date of birth Nominee's
2 Name of the Nominee Address of the relationship
Nominee of the nominee
with you
3
(Do Not Provide the nominee details incase if you are Unmarried)
4

** Certified that I have no family, as defined in para 2(vii) of Employees’ Pension Scheme, 1995 and 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) and (ii)
in the event of my death without leaving any eligible family member for receiving Pension.

Name and Address of the Nominee Date of Birth Relationship with the member

1 2 3

1. Parents Details only if Married

2. Name and address Date of birth Nominee's relationship
of the Nominee of the nominee with you
3.
(Do Not Provide the nominee details incase if you are Unmarried)
4.

Date : Form filling Date

Insert your signature here
Signature or thumb impression of the subscriber

**Strike out whichever is not applicable.

CERTIFICATE BY EMPLOYER
Certified that the above declaration and nomination has been signed/thumb impressed before me by Shri/Smt./Kum._____________________________

______________________ employed in my establishment after he/she has read the entries/entries have been read over to him/her

by me and got confirmed by him/her.

Place : ________________

Signature of the employer or other

Authoried Officers of the Establishment.

Designation
Dated the : ____________________

Name & Address of the Factory/

Establishment or Rubber Stamp Thereon
 New Form : 11 - Declaration Form
(To be retained by the employer for future reference)

EMPLOYEES' PROVIDENT FUND ORGANISATION

Employees' Provident Fund Scheme, 1952 (Paragraph 34 & 57) and
Employees' Pension Scheme, 1995 (Paragraph 24)
(Declaration by a person taking up Employment in any Establishment on which EPF Scheme, 1952 and for EPS, 1995 is applicable)

1. Name of Member (Aadhar Name) Name as per Aadhar

Father's Name Spouse's Name Father's Name (Mandatory) and

2. (Please tick whichever applicable) Spouse Name (If mentioned in Aadhar)
3. Date of Birth (dd/mm/yyyy) Date of birth as per Aadhar
4. Gender (Male / Female / Transgender) Gender Details
5. Marital Status ? (Single/Married/Widow/Widower/Divorcee) Marital Status
(a) eMail ID Personal E Mail ID
6.
(b) Mobile No (Aadhar Registered) Mobile Number
Whether earlier member of the Employee's Provident Fund Yes - If you had PF account previously, else tick No
7. Yes / No
Scheme, 1952 ?
Whether earlier member of the Employee's Pension Yes - If you had Pension Scheme previously, else tick No
8. Yes / No
Scheme, 1995 ?
Previous Employment details ? (If Yes, 7 & 8 details above)
UAN Number - You may refer your previous payslip
a) Universal Account Number (UAN)
b) Previous PF Account Number Previous PF Account Number
9.
c) Date of Exit from previous Employment ? (dd/mm/yyyy) Last Working with the previous organization

d) Scheme Certificate No (If issued) Leave it blank - Do not enter any details
e) Pension Payment Order (PPO) (If issued) Leave it blank - Do not enter any details
a) International Worker Yes / No
Yes - If International Worker, else No (Mandatory - tick Yes or No)

b) If Yes, state country of origin (name of other country)
10.
c) Passport No.
d) Validity of passport (dd/mm/yyyy) to (dd/mm/yyyy)
KYC Details : (attach self attested copies of following KYC's)
If International Worker - Mention country of origin
Mention only if you are an international Worker
Mention only if you are an international Worker
Must Enclose Scan copy for the following documents

a) Bank Account No. & IFS Code Active Bank account details - not necessarily salary account
11.
b) AADHAR Number Aadhar Number

c) Permanent Account Number (PAN), If available PAN Number

After Sep 2014 earned EPS

First EPF Member
Enrolled Date
12.
Mention first company's
Date Of Joining
First Employment EPF Are you EPF Member If Yes, EPF Amount If Yes, EPS (Pension)
(Pension) Amount Withdrawn
Wages before 01/09/2014 Withdrawn? Amount Withdrawn?
before Join current Employer?
Mention PF Contribution /
Basic Salary of
First Company
Yes / No Yes / No Yes / No Yes / No

UNDERTAKING
1) Certified that the particulars are true to the best of my knowledge
2) I authorise EPFO to use my Aadhar for verification / authentication / eKYC purpose for service delivery
3) Kindly transfer the fund and service details, if applicable, from the previous PF account as declared above to the present PF 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
4) In case of changes in above details, the same will be intimated to employer at the earliest.

Date : Date Of Joining Signature of the Candidate

Place : Joining location Signature of Member

DECLARATION BY PRESENT EMPLOYER

A. The member Mr./Ms./Mrs. ……………..…………………….. Has joined on ……………………….and has een alloted PF Number ……….……..

B. In case the person was earlier not a member of EPF Scheme, 1952 and EPS, 1995: ((Post allotment of UAN) The UAN alloted or the member is)
Please Tick the Appropriate Option : The KYC details of the above member in the JAN database
Have not been uploaded Have been uploaded but not approved Have been uploaded and approved with DSC

C. In case the person was earlier a member of EPF Scheme, 1952 and EPS 1995;
The KYC details of the above member in the UAN database have been approved with Digital Signature Certificate and 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.

Date : Signate of Employer with Seal of Establishment

 ?kks"k.kk i=k DECLARATION FORM QkeZ&1@Form-1
?kks"k.kk i=k deZpkjh }kjk Hkjk tk,xkA QkeZ ds LkkFk iksLVdkMZ vkdkj ds nks QksVksxzkQ Hkh yxk, tkus pkfg,A QkeZ Hkjus ls igys
ihB i`"B ij nh xbZ fgnk;rksa dks Hkyh&Hkkafr i<+ ysuk pkfg,A ;g QkeZ fu%'kqYd gSA
To be filled by employee after reading instruction overleaf. Two Postcard Size phtographs to be attached with the
form. This form is free of cost.
¼d½ chekÑr O;fDr ds fooj.k ¼[k½ fu;kstd ds fooj.k
(A) INSURED PERSON'S PARTICULARS (B) EMPLOYER'S PARTICULARS

1- chek la[;k@Insurance No.
2- uke ¼Li"V v{kjks esa½
Name in block letters
3- firk@ifr dk uke
Father's/Husband's Name Father's/Husband's Name
4- tUe dh frfFk
Date of Birth
Date Of Birth as per AADHAAR
Leave it blank - Do not enter any details 9- fu;kstd dh dwV la[;k
Leave it blank
Employer's Code No.
Name as per AADHAAR 10- fu;qfDr dh rkjh[k fnu eghuk o"kZ
Date of Appointment Day Month Year
Actual Date Of Joining
11- fu;kstd dk uke vkSj irk@Name & Address of the Employer
fnu eghuk o"kZ 5- oSokfgd fookfgr@ __________________________________________________
Legal Entity Name and Registered Office Address (Legal Entity Name
available at the bottom of 1st page in Offer Letter)
Day Month Year izkfLFkfr vfookfgr __________________________________________________
Marital fo/kok __________________________________________________
Status M/U/W 12- ;fn igys fu;kstu esa jgs gSa rks Ñi;k fuEufyf[kr C;kSjs nhft,
6-fyax@Sex iq-e-/M.F. In case of any previous employment please fill up the details as under.

7- orZeku irk@Present Address
Present Home Address
______________________
And your personal email ID
______________________
______________________
fiu dksM
Pin Code
VsyhQksu uEcj@bZ&esy irk@
8- LFkk;h irk@Permanent Address ¼d½ fiNyh chek la[;k
______________________
Permanent Home Address (a) Previous Ins. No.
And your personal email ID
______________________ ¼[k½ fu;kstd dwV la[;k
______________________ (b) Employer's Code No.
fiu dksM
Pin Code ¼x½ fu;kstd dk uke o irk
VsyhQksu uEcj@bZ&esy irk@ (c) Name & Address of the Employer

'kk[kk dk;kZy; vkS"k/kky;

Brach Office Dispensary
VsyhQksu uEcj@bZ&esy irk@e-mail address
¼d½ e`R;q dh fLFkfr esa udn fgrykHk ds Hkqxrku ds fy, d-jk-ch- vf/kfu;e] 1948 dh /kkjk 71@d-jk-ch- ¼dsUnzh;½ fu;e] 1950 ds fu;e 56¼2½ ds varxZr ukfer ds C;kSjsA
(c) Details of Nominee u/s 71 of ESI Act 1948/Rule-56(2) of ESI (Central) Rules, 1950 for payment of cash benefit in the event of death.

uke@Name ukrsnkjh@Relationship irk@Address

Nominee can be Spouse, Children, Parents Nominee's relationship Nominee's address is manadatory
with you

eSa ,rn~}kjk ?kks"k.kk djrk@djrh gwa fd esjs }kjk izLrqr fd, x, fooj.k esjh tkudkjh vkSj fo'okl ds vuqlkj lgh gSA eSa vius ifjokj ds lnL;ksa esa gq, ifjorZu dh lwpuk
15 fnu ds Hkhrj izLrqr djus dk opu Hkh nsrk gwa@nsrh gwaA
I hereby decalare that the particulars given by me are correct to the best of my knowledge and belief. I undertake to intimate the corporation any
changes in the membership of my family within 15 days of such change.
Insert your signature here

fu;kstd ds izfrgLrk{kj chekÑr O;fDr ds gLrk{kj@vaxwBk fu'kku

Counter signature by the employer Signature /T.I.of IP.

lhy lfgr gLrk{kj

Signature with seal
¼?k½ chekÑr O;fDr ds ifjtuksa dk fooj.k
(D) Family Particulars of Insured person
Ø-la- uke QkeZ Hkjus dh rkjh[k deZpkjh ds lkFk ukrsnkjh D;k muds lkFk jg ;fn ugha rks vkokl
SI. No. Name dks vk;q@tUe&rkjh[k Relationship with the jgs gSa\ crk,a dk LFkku n'kkZ,a
Date of Birth/Age as on Employee Whether residing If' No' state Place of
date of filling form with him/her. Residence
gk¡@Yes ugha@No dLck@Town jkT;@State
Family Details

d-jk-ch- fuxe vLFkk;h igpku i=k ¼fu;qfDr dh rkjh[k ls 3 eghus rd oS/k½

ESI Corporation Temporary Identity Card (Valid for 3 month from the date of appointment)
uke@Name
chek la[;k@Ins. No. fu;qfDr dh rkjh[k@Date of appointment
'kk[kk dk;kZy; vkS"k/kky; QksVks ds fy, LFkku
Branch Office Dispensary (Space for photograph)
Insert your photograph here
fu;kstd dh dwV la[;k o irk (Passport Size)

Employer's Code No. & Address

oS/krk
Validity Insert your signature here

rkjh[k chekÑr O;fDr ds gLrk{kj@vaxwBs dk fu'kku lhy lfgr 'kk[kk izca/kd ds gLrk{kj
Dated Signature/T.I. of I.P. Signature of B.M. with seal
 vuq n s ' k
INSTRUCTIONS

1- QkeZ&1 dk izs"k.k d-jk-ch- ¼lk/kkj.k½ fofu;e] 1950 ds fofu;e 11 o 12 ds varxZr fofu;fer fd;k tkrk gSA
Submission of Form-I is governed by regulation 11 & 12 of ESI (General) Regulations, 1950

2- ßdqVqEcÞ ls fdlh chekÑr O;fDr ds fuEufyf[kr lHkh vFkok dksbZ ukrsnkj vfHkizsr gS%&
vFkkZr~%& ¼1½ fookfgrh ¼2½ chekÑr O;fDr ij vkfJr dksbZ /keZt ;k nÙkd vo;Ld vkfJr ckyd] ¼3½ dksbZ ckyd tks chekÑr O;fDr
ds miktZuksa ij iw.kZr% vkfJr gS rFkk tks ¼d½ f'k{kk izkIr dj jgk gS] muds 21 o"Z dh vk;q izkIr dj ysus rd ¼[k½ dksbZ vfookfgr iq=kh]
¼4½ dksbZ ckyd tks fdlh 'kkjhfjd vFkok ekufld vilkekU;rk ;k pksV ds dkj.k f'kfFkykax gS rFkk f'kfFkykaxrk jgus rd chekÑr O;fDr
ds miktZuksa ij iw.kZr% vkfJr gS] ¼5½ vkfJr ekrk&firk] ¼C;ksjs gsrq d-jk-ch- vf/kfu;e] 1948 dh /kkjk 2 ds [kaM 11 dks ns[ksa½A
“Family” means all or any of the following relatives of an Insured Person namely:-

(i) a spouse (ii) a minor legitimate or adopted child dependant upon the I.P.; (iii) a child who is wholly dependant on the
earnings of the I.P. and who is (a) receiving education, till he or she attains the age of 21 years (b) an unmarried daughter;
(iv) a child who is infirm by reason of any physcial or mental abnormality or injury and is wholly dependant on the earnings
of the I.P. so long as the infirmity continues; (v) dependant parents (Please see Section 2 clause 11 of the ESI Act 1948 for
details.

3 igpku&i=k vgLrkUrj.kh; gSA

Identity Card is Non-Transferable.

4- igpku&i=k ds xqe gksus dh fLFkfr esa fu;kstd@'kk[kk izca/kd dks rRdky lwfpr fd;k tk,A
Loss of Identity Card be reported to Employer/Branch Manager immediately.

5- fdlh izdkj dh xyr lwpuk nsus dh fLFkfr esa d-jk-ch- vf/kfu;e] 1948 dh /kkjk&84 ds rgr dkuwuh dk;Zokgh dh tk ldrh gSA
Submission of false information attracts penal action Under Section 84 of ESI Act. 1948.

6- ubZ fu;qfDr dh fLFkfr esa Hkyh&Hkkafr Hkjk gqvk ;g QkeZ fu;qfDr ds nl fnu ds Hkhrj lacaf/kr 'kk[kk dk;kZy; esa vo'; gh izLrqr fd;k
tkuk pkfg,A foyEc dh fLFkfr esa fu;kstd ds fo#) /kkjk&85 ds rgr dkuwuh dk;Zokgh dh tk ldrh gSA
This form duly filled in must reach the concerned Branch Office within 10 days of appointment of an Employee. Delay
attracts penal action under Section 85 of the Act, against employer.

7- chekÑr O;fDr gksus ds ukrs vki o vkids ifjokj ds vkfJrtu fpfdRlk fgrykHk izkIr dj ldsaxsA vU; udn fgrykHk gSa] ¼1½ chekjh
fgrykHk ¼2½ vLFkk;h viaxrk fgrykHk ¼3½ LFkk;h viaxrk fgrykHk ¼4½ vkfJrtu fgrykHk ¼5½ izlwfr fgrykHk ¼efgyk deZpkjh ds fy,½A
As an insured person you and your dependant family membes are entitled to full medical care. The other benefits in cash
include (1) Sickness Benefit (2) Temporary Disablement benefit (3) Permanent disablement Benefit (4) Dependants benefit
and (5) Maternity Benefit (in case of woman employees) subject of fulfillment of contributory cnditions.

8- vf/kd tkudkjh ds fy;s Ñi;k fuxe ds osclkbV dks nsa[ksa ;k 'kk[kk dk;kZy; ;k {ks=kh; dk;kZy; ls laidZ djsaA
For more details please contact website of ESIC at www. esic.org. in. or contact Regional Office or Branch Office.

dsoy 'kk[kk dk;kZy; esa iz;ksx gsrq

For Branch Office Use only

1- chek la[;k vkoaVu dh rkjh[k %

Date of allotment of Ins. No. :_________________________________________

2- vLFkk;h igpku i=k tkjh djus dh rkjh[k %

Date of Issue of T.I.C. :______________________________________________

3- vkS"k/kky; dk uke@la[;k %
Name /No. of Dispensary : ___________________________________________

4- D;k vU;ksU; fpfdRlk O;oLFkk miyC/k gS\ ;fn gkaa] rks mYys[k djsa %
Whether reciprocal Medical arrangements involved. if yes, please indicate :

'kk[kk izcU/kd ds gLrk{kj

Signature of Branch Manager

Ø-la- uke QkeZ Hkjus dh rkjh[k deZpkjh ds lkFk ukrsnkjh D;k muds lkFk jg ;fn ugha] rks vkokl
SI. No. Name dks vk;q@tUe&rkjh[k Relationship with the jgs gSa\ crk,a dk LFkku n'kkZ,a
Date of Birth/Age as on Employee Whether residing If' No, state Place of
date of filling form with him/her. Residence
gk¡@Yes ugha@No dLck@Town jkT;@State