Data Entry Form SBS BssA5 Dictinctly Ahead Date of Birth Position No: For Office Use Only ae: Joining Date: / Personal Data Last Name ( Surname ) First Name Middle Name Known as Religion Hindu / Buddhist / Christian / Muslim / Sikh / Parsi / Jainism Basic Salary: Rs. /- Per Month Addresses Permanent Address : Local Address : Pin: City Dist : State ‘Telephone No = Mobile No. Pin. City Dist : ~ State Telephone No: Mobile No. Education : Education | Institute ‘Year of Passing Branch/ Discipline Percentage S.S.C. HS.C. LT1. Diploma BE B.Tech Blood Group: Additional Personal Data ~ (Caste) (PI. tick at appropriate column ) NT 1/2/3/4_| OPEN OBC ST SBC VI__| OTHERNew Form Wo.-1 ~ Declaration Form (vo beretaned oy te ngoyerfr pire rereee) EMPLOYEES’ PROVIDENT FUND ORGANISATION ‘oly Prose un Shae, 082 Pagagh 4857) enployer Pane Sener, 185 (Pang 29) (Decaraten by a person aking up employment inary estate on which EPE Sebeme, 1052 ano EPS, 1956 aptabl) 7, | Rane othe reid iin | 2, |FathersName [] Spouse's Name CJ (Please tek whichover i appcable) Date of Birth: (DO/ MMT YY) ~[ ender (ae Female nego) 7 ‘Marital Status.” (Married/\Unmarried/ Widow/Widower/Dworce: |(@) Email 1D: a = (e)_Mobie no, ‘Whether earlier @ member of Employees’ Provident Fund Scheme, ‘Yes/No 52 @_ | Whether earier a member of Employees Pension Scheme, 1995 “Yes/No Previous employment details: [if Yes to 7 AND/OR 8 ibove] 4 8) Universal Account Number 1b) Previous PF Account Number ~ ® ©) _Date of ext from previous employment: (DD/MMIYYYY) E ‘Scheme Certfcate No. (issued) —— - 7 Pension Payment Order (PPO) No. (if issued) 3)_Tnternatonal worker Yes/No Wes, ndaName of her county) @)_ Passport No. - 7 9) Valcity of passport {(OD/MM/YYYY) to (DDIMMINYYY)] 7 KYC Details: (attach self attested copies of following KYCS) +1 | 3) Bank Aézaunt No & TFS Cade a 10 0) AADHAR Womber [@)_ Permanent Account Number (PAN), Wavalabie ~ [UNDERTAKING 2) Ceted tha the particulars are rue tothe best of my knowledge. 2}, Tahoe EPFO to use my Aahar for vereaton/authentclior/eKYC purpose for service delvery. 3). Kindly transfer the funds and serie deta, if apocabe, tara the previous PF account as delared above tothe present PF. Account. (he transfer would be posible only ifthe identified KYC deta approved by previous employer has been veri by present employer sing hes Digtal Signature Cericate) 4, Incase of changes in above deta, the same vil be intimated to employer at the earliest. ate Pace: ‘Signature of Member [DECLARATION py PRESENT EMPLOYER AL The member Mrs. sow MAS ied on vm and has been alloted PF Number ‘8, incase the person was ear not a member of EPF Scheme, 1952 and EPS, 1985: + (Post allotment of UAN) The UAN alted forthe member is + Please Tick the Appropriate Option: ‘The KYC details ofthe above member Inthe UAN database rave not been uploaded © Have been usoaced but nt approved Have been uploaded ard approved with OSC C_Incase the petson was ealer a member of EPF Scheme, 1952 and EPS, 1995 ‘The above PF Account puber/UAN of the mernbe” as mentioned in (A) above has been tagged with hehe UANY/Previous enter ID as declared by member. + Please Tick the Appropriate Optior ©The KYC deta ofthe above member Inthe UAN database have been aparoved with Digital Signature CertNeate and transfer request Pas been generated on portal, [EAS be DSC of establishment ace not regstered with EPFO, the member hasbeen informed to fle physical claim (Form 13) for transfer of funds rom his previous establishment. Date ‘Snalue of Employer vith Seal of Establishment‘WIG WA DECLARATION FORM vere Form seo aster cer soe ent Be hea sree a A whan oe A a a A a Wea ‘te ese te ecract at wot-e Ug er eg ae oo FgeT 81 ‘To bo fled by omployoe aor reacng instruction overenl, Two Postoard Size phographs tobe attached with the form, This form i oe of cost. (3) dog as & Feet (@) Praia # Recor (A) _ INSURED PERSON'S PARTICULARS (©) _EWPLOYER'S PARTICULARS fata earner vo Ra a ae on _ Eenlyers Code No far ere a a3 raga @ ate =] a | a eas Daf arent Dey | _ontn_| Your Reva era Feber ann Hee aire Swan Aan othe Epler [ca Rie Ba sar [we] aie |e | | ————— = Date o itn Day]Montveay sien |steaea | CS Stowe WOW | Tare RET aE AT FaiterSoxfuscaae| | meseotary previ emsoyrn pace pine le ae nc [rere Access — cea e-Pomanon adoes | |[ RA Oe " GS rs bse (a) Previous ins. No. | | Jerre semper Cade Na. aia Saar Poca LETT | pecee CLIT) Jay mae a a var [sta et ce rte seve wav Cc) Name Acres ofthe Empoyr lemen once Dipeneay [str ee vo ml dose (=) 5g eh Ra He Ree @ rar ya, I, oe wr Ti (le ee, 50 Rae Sa) ao ae Ay (© Detas of Nominee u's 71 of ES Act 1948™ule-562 cf ESI (Central) Rules, 1950 or payment of cash bor inthe evert of death Wehame wae Ralaoraip acd gra co wh ge Reg Fe A eee ar arg By Have are ace He wT A ST ser ise nea ac al tea Wt GEA EL herby decalare thatthe parculare gn by me are conect tothe best o my knowadgo ana be ‘hangos inthe mambereip omy amy wit 16 ye of uch change. rere timate he corporation any rie & stern steps ar eenevsip Be (Counter gnatreby the employer ‘Signatur T1011 ‘er afer ere ‘Signature wy sal (a) erg a oe a aces (0) Fary Paral of Inaued person =e, aH waa eae | eens we mat aa ae Js'no. | name Borges | Aalatonmip wth be wen art Joa ot srvage aton | Employee WF Ne te Pace ot cata ting tn ‘esgone. = ee [Ne | Soon | 1 Saf, fe em ea (Rafe oe a 9 nb wt) 1 Cerperaton Tempera eet Card (aor anthem te ata of appsietert) hme er Wana No a wa ater ‘war aeiae col 2 8 fe ee Branch foo Dispensary (spec Yo phaogech) Riera wen Epoyera Code No 8 Adass tn Valay nts arg as & eee Fa ‘fe ats ar sae Fa Dates ‘Sgnturr ol ‘Sipature of BM. win oaseat INSTRUCTIONS 1, a ar deer A (amare) RP, 1950 APRA an Faz & ofa PARA Ra TAT ty Submission of For is governed ty reguation 11 & 12 of ES! (General) Reguatons, 1950, 2 a” ahr sa Prat aa fra aA tee aie ral (1) Ret (2) tga ar wart NE ent a ce arene oer aro, (3) aR ares tt aS & cot oe whe: ar & ge a () fare arena ter 8, gw 21 ak at ur wr AF am (@) aHE aE EH, (9) a are Pt eros over aes one ae eee er & ser era eT es AR aT oop oe gee one 8, (6) srr rarer, (ai Bg war. fePtam, 194s UT 2 we 11 aT BA) “Famiy’ meen al or any ote folowing relates ofan insured Person namay~ (0 spouse (i) amino egtmate or adopted chile dependant upon tho LP; (i) cid whos wholy dependant on he arrings ol be LP. anc who (a) reeaingedueaten lhe or she aise age of 21 years (2) an unmatieg daugher (1) cha who inte by reason of ny physcal of mental abnormally ory and is wholycepencant onthe earings cite LP ong este infty contues;(y) cepandant parents (Pease soo Secton 2 cause 11 othe ESI Act 1948 for corals 3 meats sera 1 Iconty Card is Non-Transterte 4. agers ro Ra Rear wees ace gt ea TE Loss of identity Garé be reported to Empoye/Branch Manager meta. 5. fal are ate yee oH Rae aca, RM, 1948 a arse mee ar art A oT wet BI ‘Submission of ase information atvacts penal acton Under Section 64 of ES! Act. 1946 6. E Prof Rea eur er ga ae rd Fagfir ae Rr & te eae se ral Hf raae A sg Fat cara eu Fre of ae Pts & Roe eras & ae agi mda) A ar wad B This form duly filed in must reach the concermed Branch Offce wiin 10 days of appointment of an Employee. Delay tracts pena action under Section 8S ofthe Act, egainst employer 1 ager sain arte are ere nfs fae Fea are ae a are a Rrer &, (1) fo fer (2) ent ore fer (8) eet iter rae (4) carer (5) re Pera (a ae fe) ‘As an insured person you and your dependant larly membes are entitled to fll medical cae, The othar beneis in cash Include (1) Sickness Benefit 2) Temporary Disablement bone (3) Permanent alsablement Benet (4) Dependants bent ‘and (5) Maternity Benefit (n case of woman employees) subect of ulllment of contributory enon. 8, firs arent RRA poet Fe ergs at Bar a rae das ara @ wes 3 For more deals please contact website of ESIC at ww. esic.og. in. or contact Regionel Otfee or Branch Off, Bae ren arate # sain Bg, For Branch Cco Use only ter ion aries ts Date of allotment of ns. No. ready ere oH adh a? a a Dato of Isave of TLC. : horus ae [Name /No, of Dispensary ear ore Pre argon overar Br aE wt gor BE \Winether reciprocal Medial arrangoments involved. i yes, please inciate: ar sara rea Signature of Branch Manager aa ca waa aa aaa Sat ee] ae ao I No Name aangartaiia | Relaorshp wah the "een vw er att Jose ot antago at on Employee Wetter fesng | i No, sale Pace of dat of lng fom wth eve heslaorce a SEL | owe eSa SAIAI Dirkinetly Ahead BANK ACCOUNT INTIMATION FORM To, ‘The Finance Dept, Bajaj Auto Limited, ‘ Akurdi, Pune — 411 035 Dear Sir, I hereby request you to make my salary and other payments by way of directly crediting the amount to my bank account. The details of which are furnished below :- | also confirm that if my bank account is credited by the amount of my salary cheque, it will be deemed to be an acknowledgement for the receipt of salary and other payment from you from time to time. 1. Name in full 2. Full Ticket No. : as 3. Name of Bank : Branch : 4, IFSC Code : 5. Bank A/c. No. : L 6.A/c.Type : Savings Cancelled cheque of my bank account number, mentioned at Sr. No. 5 above, is attached herewith, Signature Name: Date :