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P(mrullt Adrires:, of
Tex.Ju

S1gilfl.n> of fCOOE'

_J
Nore;- OA.i COP')' of tJ-p ProtogrnJit JXNed above smuld Ii attoctm with this form

Sigittue of UtOj PO/l)JIO

(\\1th SliUll>I Sigmt~ of Hoodrrmtf.'lfPrird,n
(\\;th Stmq:>)
 I ,,trr, hlr,. 1 t ff lr 1 tl)
IJnr,,fnra t io n Furr n
( lu hl'l trlt1ln,.,J l,y lftn I 1,11,l•,1,., f,,, f11t11to r,;fr:rr,,,_
1

Employees' Provident Fund Organlzat,ion

T Hf E~vl PL l) Y[b ' PIWVIDl'N I F-UNI )I, Sc111 Ml I 1!Jf,/ (I J/\11/1,11/ J'f , 14 I';;,/)
&
TH E E1v1Pt0Ycrs ·Prn s 10N Su 1r Ml , 199~, (l'A1w ,111•1·11 ?4}

y A P RS N TA I G P I O M A S B IS < , •~'L!.l.{J.1.~:.f:Jfv IL!AJ LJ..ilJJ IL;i__QJ.f..l.&.,

1952 AND(OR EMPLOYEE<,' PFNSION Sf;H[Mf 199!i ,,, /\1'1-'i ts.~
(PLEASE GO THROUGH THE INSTRUCTIONG)
1) NAME

f
(MR.~~- I MRS] t II II II II ./ ./ .1' tJ II rI /!-1
2) DATE OF BIRTH
{PLEAOE ncK)
~ -t~1-=tE1-i-1I .'-8LJ
j .' .1[ d H
f°l nMlylylTI
0

3) FATHER'S/
HUSBAND'S NAME

~r r-
i
~I /-,1'--;-I
Tri t-t-11-+/-+l-t-1-t-,-1-+-I-t-1 '-----t/--tl-;-/-r-/--r-/--r--
-i---/--t-1

111.1111, .11111, I., ...

r-1/ 1 -----.
i i

4) RELATIONSHIP fN RESPECT OF (3) ABOVE

(PlEASE TICK)
[ FATHER
jr-----_r--------,
I HUSBAND
r 1

5) GENDER
(PLEASE TICK)
I
I
MALE FEMALE
ITAANSGe.o~ I
6) MOBILE NUMBER
(IFANY)

7) EMAIL ID (IF ANY)

I I I I I
8) WHETHER EARLIER A MEMBER OF THE EMPLOYEES' PROVIDENT FUND SCHEME, 1952?
(PLEASE TIO<) YES
9) --------------
WHETHER EARLIER A MEMBER OF THE EMPLOYEES' PENSION SCHEME, 1995?
NO

(PLEASE TIO<) YES NO

IF RESPONSE
AT TO ANY OR BOTH OF (8) & (9) ABOVE IS YES, THEN
(10,11&12): MANQATORHY FILL UP THE PREVIOUS EMPLO"t'MfNT DETA.HS

Page 1 of 3
 A P_f;E
3
VI OUS EI\IPLOYt-l[N
JO). THE DETAILS OF THE T DEl AIL S
UNIVERSAL ACCOUNT NUM
BER (UA N) OR PREVIOU
S PF MEMUEf{ ID:
UAN
OR
I I I I I I I
PREVI OUS PF MEM
BER ID REGION CODE

------
OFFICE CoDE ESTABI ISHMENT ID Ex TENSION Ar,cou~lf Nu1A&.k
• . • t • " •.• •
: • I I I

12) (A) IF SCHEME CERTIFICATE 1

ISSU
ED FOR-PREVIOU-
S EMPLOY
-
(B) IF PENSION PAYMEN -
MENT, THEN SCH-
EME CER-
T ORDER (PPO) ISSUED TIFICATE-
NUMBER: _ _ _ _
FOR PREVIOUS EMPLOY _
MENT, THEN PPO NUM
8. BER: _ _ _ _ _
OTHER DETAILS _

13) I NTE RNATIONAL WORKER

( PLEASE TIC K) YES NO

IF THE REPLY TO ( 13)

ABOVE IS YES, THEN
13(A ) COUNTRY OF ORIG ENTER THE DETAILS
IN Please Tick IN 13( A), 13( B) &
13( C):
INDIA
OTHER THAN INDIA (IF
YES, PLEASE
MENTION NAME OF THE
COUNTRY

13(8) PASSPORT NUMBER

13(C) PASSPORT VALID FRO

M
0 0
I l IM IM IY IY IY IY
I
To
0 0
l l IM IM IY ly ly ly
l
14) EDUCATIONAL
ILLITERATE NON-
QUALIFICATION MATRIC SENIOR
MATRIC GRADUATE POST 1
SECONDARY
(PLEASE TICK) GRADUATE DOCTOR \ PRO
TECHNICAW \
FESSIOOAL

15) MARITAL STATUS MARRIED UNMARRIED

\ \
(PLEASE TICK) WIDOW/ WIDOWER DIVORCEE

16) SPEOALLY AEUD YES No

( PLEASE TICK)
IF YES, TICK THE CATEGORY
LOCOMOTIVE
VISUAL HEARING

Page 2 of 3
C

I l 7) KYC DETAILS KYC DOCUMENT TYPE

BANK ACCOUNT· 1"'
NPR/AADHAAR
PERMANENT ACCOUNT
NUMBER (PAN)
PASSPORT
NAME AS ON l<YC DOCUMENT NUMFJ~ -
_Pl MAt•r',, fl 1-!1_1

DRIVING LICENCE
)

ELECTION CARD
RATION CARD
ESIC CARD

" Mandatory Field (NQIE: BANK ACCOUNT NUMBER (ALONG WITH IFSC CODE) IS MANDATORY. YOU
ARE HOWEVER ADVISED TO PROVIDE All KYC DOCUMENTS AVAlLABLE WITH YOU IN ADDITTON 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 AND BELIEF .
8 . I N CASE, EARLIER A MEMBER OF EPF SCHEME, 1952 AND/OR EPS, 1995,
(I) I HAVE ENSURED THE CORRECTNESS OF MY UAN/ PREVIOUS PF MEMBER ID.
(11) THIS ll,IAY 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
E!1IPLOYER USING HIS DIGITAL SIGNATURE CERTIFICATE) .
(111) I AM AWARE THAT I CAN SUBI\IIT MY NOMINATION FORM THROUGH UAN BASED MEMBER PORTAL.

DATE:
PLACE:
SIGNATURE OF MEMBER
DECLARATION BY PRESENT EMPLOYER
A. THE MEMBER Mr ./MS.jf.l r'> ...................... .... HAS JOINED ON····· ··-·-·-·····" AND HAS BEEN ALLOTTED PF MEMBER ID

8. IN CASE THE PER.500 W/'S EARLIER NOT A MEMBER OF EPF SCHEME, 1952 AND EPS, 1995:
(POST ALLOTMENT OF UAN) THE UAN ALLOTTED FOR THE MEMBER IS ··········--··
PLEASE TICK THE APPROPRIATE OPTION:
THE KYC DETAILS OF THE ABOVE MEMBER IN THE UAN DATABASE
n HAVE NOT BEEN UPLOADED
n HAVE BEEN UPLOADED BUT NOT APPROVED
n HAVE BEEN UPLOADED ANO APPROVED WITH DSC
C. IN CASE THE PERSON WAS EARLIER A MEMBER OF EPF SCHEME, 1952 AND EPS, 1995:
THE ABOVE MEMBER fD OF THE MEMBER AS MENTIONED IN (A) ABOVE HAS BEEN TAGGED WITH HIS/HER UAN/PREVIous
MEMBER ID AS DECLARED BY MEMBER.
PLEASE TICK THE APPROPRIATE OPTION:-
n THE KYC DErAILS OF THE ABOVE MEMBER IN THE UAN DATABASE HAVE BEEN APPROVED WITH DIGITAL
SIGNATURE CERTIACATE ANO TRANSFER REQUEST HAS BEEN GENERATED ON PORTAL.
n As THE DSC OF ESTABUSHMENT ARE NOT REGISTERED WITH EPFO, THE MEMBER HAS BEEN INFORMED TO FILE
PHYSICAL CLAIM (FoRM· 13) FOR TRANSFER OF FUNDS FRQ\1 HIS PREVIOUS ESTABLISHMENT.

DAfE; SIGNATURE OF EMPLOYER WITH SEAL OF ESTABLISHMENT

Page 3 of 3
 /1 _____
/ NAMEOFTHELOCALBODY - - ~Tu:
N_A_M_E_O_F_T_H_E_S.::..C....:H.:.O..:O..::...:L::..:__ _ __L_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _l\~LO~:!:.:~~
~_!:~:~~~~L.: . . .:_~:______ _
ISL. NO NAME OF THE TEACHER TYPE OF THE
TEACHER
FIXED SALARY AMOUNT
PER MONTH
DATE OF
THE
J\
j l I
I 2 \
I 3

I I
I 5 \
I 6 I
I 7 \
I 8

I
I 10

I 11

I 12

I 13

I l<l

I 15
I 16

I l7

I 18

I 19

I 20

I
The above mentioned teachrs's details are confirmed from School Records

■ SIGNATURE & SEAL OF THE PRII.JCIPLE / HEADMASTER OF THE SCHOOL SIGNATURE & SEAL OF THE SECRETARY OF LOCAL BODY