PERSOLKELLY India Pvt Ltd

(formerly known as Kelly Services India Pvt Ltd)

unltech Cyber Park
Unit No- 1202-1204, 12th Floor, Tower-C

rJJ PE RSOLKELLY Sector -39 Gurgaon

122002 Haryana
Email: lnfo_ln@persolkelly.com
Website: www.persolkelly.co.ln
CIN U74910KA2001PTC02951

DeacEmploy~, G;,
This is in reference t o your appointment with our client gJ" ~
~
b~ n
t<ovlJ , d at PERSOLKE LLY India Pvt Ltd
depute_
(formerly known as Kelly Services India Pvt Ltd). Request you to pleasei ll the enclosed forms completely and submit the necessary proofs. These

formalities must be completed wit hin two days of Joining. All information requested in this form is Mandatory.

You are requested to complete these Joining formalities to receive appointment letter.

Personal Particular Form duly signed by the employees own handwriting.

Form 2, Form 1, Form 11, Form F, Form D, Form X (To be Filled)
Resume
Education Proof
PAN Card
Aadhaar Card
Four passport size photographs.
Documents of previous organization (Offer Letter/Appointment Letter/ Exp Certificate)
Salary Slip of previous organization (last 3 months)

Consent by Employee:
Pvt Ltd
I Hereby confirm all the below details to be true and correct and to the best of my knowledge, I aut horize PERSOLKELLY India
the applicat ion.
(formerly known as Kelly Services India Pvt Ltd) to carry reference check with past employer and references in connection with
to the collection,
I hereby confirm that I have read through and agreed to the terms of PERSOLKELLY Privacy and Company Policies, and consented
use and disclosure of the personal data by the employer and our affiliates, in accordance with company Policy.

dismissal if
I understand that any miss representation or omission of information will be sufficient reason for withdrawal of offer or subsequent
confirm to the fact that I would be personally responsible for
employed with immediate effect. I understand its implication to the fullest and hereby
actions done, in contravention to established policies and procedures.

If you ~ hdJf'iour consent, please drop us an email to let us know.

Slgna~ of the emploYJe I I

NameofEmployee: \Y\'1.~<..(..1p \(.vt«\C,19-'\ ~
Date:

Name of client

Date of Joining

Person Code (Employee Code)

Name of Consultant/Sr Consultant:

Date:
For further query please contact on 0124-4726666

llPa g e
 PERSOLkElly
f rmerly known as Kelly Services 1~
(o Unitech
Unit No· 1202-1 204, 1 2th Floo,,
Sector -39

f.1 PE RSOLKELLY 12200 2

Email: info_in @persolkel",
Websi te: WW'/'!_. ersolkel .
CIN U7491 0KA2001PTCO

S)
(Please fill In your own handw riting, In BLOCK LmER

2. Husband's Name /Fat hen'Ja me (If Applicable):

{!_)(Y'("\ ~cnoi\<,~
3. Mothe r Name : _ _ _ ~\l,:i..____::~-:::~~\L-_ _____ ____ _____
\J_,_~~~r('\
4. Date of Birth: _ )_ o_o_\ __ __ ___
__.!_'__,1_ 0_ ~_ i+ --<-- (DD/MM/YYYY) (attach proof)

5. Gender: M 0 (Check the correc t box)

6. Address:
Curren t: ©\"'d.\s.d o \<,g t:h\m1 \\ 0\ J \<~-o-y.. m9:'.(CJht rW1 , K~ h

Pin Code: ~Cl .So c~

Permanent: gJ ht-1hJ~ \(q OY\ obJ \q ,t
\.< ~~c t~•V~-'.5!>~1 pU.,, I k.o k

~S~
Pin Code: --~---=2..: e_ o_\~ - - -
_ _ _ __
Telephone: _ _ _ _ _ _ _ _ _ _

7 . PAN No: £X Vf RYS .2. ':36)

8. Aadhar Card No: 5 lj (,YO 2... IS
:J 8 <2...3
compl iance and Tax Implication.
applied share ackno wledgment slip t o avoid
(Mand atory): Pan Card & Aadhar Card: If not

9. Marita l Status : ~ '""t \-{_ (Single /Marri ed/Separated)

If marrie d; is your spouse employed: Yes/No

_A\~~
10. Blood Group (Mand atory) : _ ___.__.,...-
_ _ __ __ 11. Nationality: _ _ ._0') -'- --- --- --
::::Jm. . ,_..-__,'-'-s\-'-'\. , ~, -'-
_ _ _ _ __ 13. ~AN Numb er (PF Inform ation): \ Cl ~':\'
L~S ~ ~- 1
12. Passpo rt Numb er: _ _ _ _ _ _ _ _ PF accou nt)
(This info gets collec ted t o cont inue your old

_ __
_ _ _ __ 15. First Joining date with employer regarding EPFO
14. ESIC 1.P Numb er: _ _ _ _ _ _ _ _ _ withd rawn PF} (PF date of joining)
(Even though associate has
ESIC account and map in records)
(This info gets collec ted t o contin ue your old

ed i.e. Cancelled Cheque/Passbook Copy

16. Bank Accou nt Details*: (Proof to be attach

t and can be used for salary transfer to this account)

{I hereby confirm that the detail provided by me Is correc

21 Page
 PERSOLKELL Y India Pvt Ltd
(formerly known as Kelly Services India Pvt Ltd)
Unitech Cyber Park
Unit No- 1202-1204, 12th Floor, Tower-C
Sector -39 Gurgaon
122002 Haryana
Email: lnfo_ln@persolkelly.com

I 17. Educational Qualification• .. (Start with High school or equivalent)

Website: www.persolkelly.co.ln
CIN U74910KA2001 PTC02951

19. Languages Known••• (Please fill A for fluent, B for fair, C for workable)

~ a ·· :: ·

20. Emergency Contact Details•••

21. Covid Vaccination Status:

O l st Dose ~
nd
Dose D None

Ocovaxin D Covishield

REFERENCES (For Check)

capacity.
Please give names and addresses of 2 persons (not relatives) whom you know in a personal / professional

1. Name: _ ----LM \~
--'--'....._
0..Y)
___,___,, _ ~.,,_,___,___ _ __ __
_ _,___N _ _

Tel. No.: _ _ \ _O ~ ~-8~~- 6_ _ _ __ _ _ __ _

_\~'-\~<?)_ l)___

2.

3IP a ge
 PER.sol ,-{!
forrnerlY known as Kelly s ~~LL~, ;-<..
/
( erv,ce\i':'..\ ~
\Jnlt ~
Unit No- 120 2-1204 , llth ~~ht~
Q
Clar ="-~
Secto, _39'1.~~
. . 12200,"fl~:~
fJI PERSOL KELLY Email: mfo_ln @pe ar,~
rso\ke1i-, ...,
Website: www . ersolke11 t..;.
c1N U74910KA20 01 p1c c ,,
0,9~\

Declaration for Backgrou nd Verification

\
Date:

Dear

. . . d . you r deputation w ith

This is t o t poi ntment is subject to the result of background verification unng

client._-,t~4-~~~IQ'f ¥:mE9lc--1<:e.V_'.,_-
t th
In case, the information provided by you at the t ime of joining is incorrect or verification of your background is contrary to the intereS S of e
com pany t hen the company shall have the right t o terminate t he servi ces of the employee immediate ly without serving a noti ce period as
mentioned in your appointment Letter.

D_ J.\U..
Employee Signatu re ~ ~\ V...
Employe e Name: (';) \ \ L, , ..,.,__ ;{\ . .
1;:r\c,. d ~ ~ r,> f-N1 n-1 tA,\ 'f<l"-V
Dat e:

Witness Signature

Witness Name:

Date :

41 P age
 PERSOLKELLY India Pvt Ltd
(formerly known as Kelly Services Indi a Pvt Ltd)
Unltech Cyber Park

rJI PERSO LKE LLY Unit No- 1202-1204, 12th Floor, Tower-C
Sector -39 Gurgaon
122002 Haryana
Email: lnfo_ln @persolkelly .com
Website: www .persolkelly.co.ln
CIN U7491 0KA2001PTC02951

Insurance Information

· Address•
Employee Name(Self)•

.. . .
. . ..
- • I , I

% Share•
· Date of Birth• Nominee (Yes/No) • ' Relation"
Dependent Name

Spouse:

Child 1:

Child 2:

tO (J ' /.
Father: ~

guardian
If the nominated beneficiary is a minor, please mention below the name and relationship of the

Guardian Name

Relationship of Guardian

of the Employee Benefit Insurance Program of

Disdaimer- Insurance Policy (Group Personal Accident Policy/Group Health Insu rance) is a part
the Company. Policy terms applicable will be as per insurance contract between
PERSOLKELLY and the guidelines of the same will be governed by
will be used by PERSOLKELL Y & Insurer to pay the applicable Sum Assured under the Policy to the nominated
PERSOLKELLY & Insurer. Above data
to be followed will be as per applicable norms agreed
beneficiary in the event of an unfortunate death of the insured. Claim settlement process
between PERSOLKELLY & Insurer.

Date
EMPLOYEE SIGNATURE

be procured accordingly from joining kit, if not ; applicable

Note: Employee will only be eligible for benefit as per policy applicability and details would
details are only collected from record aspect.

• Mandatory Field

SI P age
 PERSOLKELLy lndl
(formerly known as Kelly Services lndlaa

~Jl PERS OL KELLY Unltech C'fbt

Unit No-1202-1204, 12th Floor, T '
Sector -39 Gur
122002 Hary;i
Email: info_ln@persolkelly.co~
Website: www.persolkelly.co.ln
CIN U7491 0KA2001PTC0295i

Acknowledgement of Policies

To,

PERSOLKELLY India Pvt Ltd (formerly known

as Kelly Services India Pvt Ltd).

Registered Office: Sri Ram Samanthu Cham

bers, No. 3287,
12th Main HAL 2nd Stage, Indira Nagar, Banga
lore-560 038 (Karnataka).

Corporate Office: Unit No-1202-1204, 12th

Floor, Tower-C, Unitech Cyber Park,
Sector-39, Gurgaon-122 002 (Haryana)

Subject: Acknowledgement of receipt of PERSO

LKELLY pollcies & compliance manual and agree
ing to adhere to the same

I hereby acknowledge that I have read and

understood the content of the following Policie
(formerly known as Kelly Services India Pvt Ltd) s which are part of the PERSOLKELLY India
Compliance Manual and Privacy Policy which Pvt Ltd
were shared with me:
1. Compliance Manual: Chapter 1- Code of Ethics
2. Compliance Manual: Chapter 2-Anti-Bribery
and Anti- Corruption Policy
3. Compliance Manual: Chapter 3- Internal Person
al Doto Protection Guidelines
4. Compliance Manual: Chapter 5 - Cyber & inform
ation Security Policy
5. Compliance Manual: Chapter 7 -Anti-Haras
sment Policy
6. Compliance Manual: Chapter 8 - Whistleblow
ing Policy
7. Privacy Policy

(individually and collectively the "Policies")

Further, I understand that PERSOLKELLY India

Pvt Ltd (formerly known as Kelly Services India
time without prior notice and I will adhere and Pvt Ltd) reserves the right to revise the Policie
agree to all such revisions made to such Policie s at any
s.

Regards

(Employee signature)

Employee Name: Mr./ Ms.

Received for & on behalf of

PERSOLKELLY India Pvt Ltd (formerly known
as Kelly Services lndla Pvt Ltd)

6\P a ge

I fief
 PERSOLKE LLY India Pvt Ltd
(formerly known as Kelly Services India Pvt Ltd)
Unitech Cyber Pa rk
Un it No- 1202-1204, 12th Floor, Tower-C
Sector -39 Gurgaon
122002 Haryana
Email: lnfo_ln@persolkelly. com
Website: www.persolke lly.co. in
CIN U74910 KA2001PTC0295 1

I
(FORM 2 REVISED)
S
UNEXEMPTED/EXEMPTED ESTABLISHMENT
NOMINATION AND DECLARATION FORM FOR s
ees Provident Funds and Employees' Pension Scheme
Declaration and Nomination Form under the Employ
ees'
Fund Scheme 1952 and Paragraph 18 of the Employ
(Paragraph 33 and 6 1 ( I l of the Employees Provident
Pension Scheme 1995)

'P R1'.\-~/5-E-P kRfiV. OM P~f'\(f\$+\ RfW·

I. Name (INBLOCKLETTERS) : Surname
Name Father' s/ Husband's Name

2. Date ofBirth: I6 IO' /q C 6 I 3. Account No. :3<J._2.Q\6b'2s:, &6'113

{!;-_
\ \.,' -=
__.__,'f'-'--"' _5. Marital Status _ _.9i!-~'-U _M
==--=-f\/ .,__.._~~6~ ,P_ _
_:__:_A-'-'-\?:_1l
4. •sex: MALE/FEMALE .:_ --tM

6. Address Permanent / Temporary: \.<\-\ ~\'.l'f1R '1-~~ D L fU D.. ( \< l'.fT~

PART -A (EPF)
nominate the person(s) mentioned below
I hereby nominate the person(s)/cancel the nomination made by me previously and
d.
. the amount stan mg to my credit in the Emolovees Provide nt Fund. in the event of my death.
to receive Jfthe nominee is minor
ee's Date of Total amoun t or share of name and address of the
Name of the Address Nomin
Birth accumulations in guardian who may
Nominee (s) relationship with receive the amount
the member Provide nt Funds to be
paid to each nomine e during the minority of the
nominee

5 6
2 3 4
I

~MJB m:- K\tE-f-¥\ M.011'\Ei~ Ml 0 ll \<{1 ~ ·I au 1/ .

l Q.ruoil vor,
.Y'~

I
of the Employees Provident Fund Scheme 1952 and should
•certified that I have no family as defined in para 2 (g) ed.
nomina tion should be deemed as cancell
acquire a family hereafter the above

• Certified that my father/mother is/are dependent

upon me.
2.

Strike out whichever is not applicable

PART - (EPS)
Para 18
en Pension in the
family who would be eligible to receive Widow/Childr
I hereby furnish below particulars of the members ofmy
event of my premature death in service.

Age Relationship with the member

Sr. No Name & Address of the Family Member

(I)

71 P age
 .C:'
~ ~

0
cl
PERSOLI(
(formerly known as Kelly s ELL~ 1
'""c~
0 ():-

,"<I· Q
ft!J PERSOLKELLY Uni\
Unit No-1202-1204, llth ~~~
S
1
\

~
r,l l.,'?/
ector .39 G
12200 2:'
Email: info_ln@ persolke~
Website: ~ k,11.,:.-;;-"I
CIN U74910KA20~

CertHied that I have no family as defined in para 2

(vii) of the Employees's Family Pension Scheme 1995
family hereafter I shall furnish Particulars there on and should I acquire a
in the above form.

I hereby nominate the following person for receivi

ng the monthly widow pension (admissible under para
event of my death without leaving any eligible family 16 2 (a) (i) & (ii) in th e
member for receiving pension.

Name and Address of

the nominee Date ofBirth Relationship with member

V;rSH\VU g'A t ~\~bl\,~,b f'-'\o'T1-\E;~

~ \·H\\<.Q ~ \<!.\ ("\ch_c,.l\(\ I

l<-~ ,(_ _~ ~~\ f W'\ t (4M

~;KO..
Signature or thumb impression of the subscriber

CERTIFICATE BY EMPLOYER
Certified that the above declaration and nomination
has been signed/ thumb impressed before me by Shri
________________ / Smt./ Miss
_ _ _ _ _ _ _ _ __ _ employed in my
establishment after he/she has
read the entries/ the entries have been read over to
him/her by me and got confirmed by him/her.

Bl Pag e
 I

PERSOLKELLY India pvt Ltd

, I d' pvt Ltd)
(formerly known as Kelly Services n ,a k
Unitech Cyber Par
Unit No- 1202-1204, 12th Floor, Tower-C
PERSOL KELLY sector -39 Gurgaon
122002 Haryana
Email : info_ln@ persolkelly.co:
Website: www.persolkelly.co.1
CIN U74910KA2001PTC0 2951

FORM-I
Payment of Wages Act.
(NOMINATION AND DECLARATION FORM)
[See rule 3)
I Name of the person making nomination (In block letters):- <J)~l)E:I='~ \.( V Mf.l\l-' R. A-V
2 Father's/ Husband's Name:-, OM ~ \l.'A \(f\S\1 Q \\V
3 Date ofBirth:- I , O( <l"b \ I
4 Gender:- f'I\~\~
5 Marital Status: - \I IV M~ ~ ~ 1:.-,l>

6 Address: -

Pennanent: 1H\Pl-\<10 \< \\- "'' 0 1-\ f\-U <l- I \< \-\ ~IH\-µ_~.! ( 6 Lpu fl I 11 ~
Temporary: _5 l(\'Y\ ~ ~ •

I hereby nominate the person(s)/cancel the nomination made by me previously and nominate the person(s) mentioned
below to receive any amount due to me from the employer, in the event of my death.

Name of the Nominee I Addre Nominee's Date of Birth Total Amount If the Nominee is minor,
Nominees ss Relationship of Share of Name, Relationship and
with Member Accumulation Address of the Guardian
s in credit to may receive the amount
be paid to during the minority of the
each nominee Nominee
1 2 3 4 5 6
V , .&.Ym\.\. i~ l\\\\~\)?
( o \\,\~ '1
\,{~(.!>\'I ~OfvlE9'\ 01{01l~1b t an'/.
l.,~l\~
"K«>-14

I Certified that I have no family, and should I acquire a family hereafter, the above nomination shaJI be deemed as cancelled.

2 •certified that my father/mother is/are dependent upon me.

3 •Strike out 'Nhichevcr is not applicable.

Signature or the thumb impression of the employed person

CERTIFJCATE BY THE EMPLOYER

Certified that the above declaration and nomination has been signed/thumb impressed before me by Shri/Smt/Miss_ __

_ _ _ _ _ _ __ _ _ _ _ _employed in my establishment after he/she has read the entries/the

entries have been read over to him /her by me and got con finned by him/her.

Signature of the officer of the establishment:

Place: -
Date: -
Name and address of the factory/establishment:

9IP age
 J
~
(formerly known as Kelly Services Ind, /'J «f
Unltech c ~'<
Unit No- 1202-1204, 12th Floor, T ~~

WJ! PERSOLKELLY Sector •39 Gu,

122002 Ha
Email: lnfo_ln@ persolketty.
Website: www.persolkel~
CIN U74910KA2001PTC029St

FromX

{See Rule 75)

Employee Card

Name and address of contractor:

Name and address of Establishment in/ under which contract is carried on:

Name of work and location of work:

Name and address of Principal Employer:

1. Name of the workman:

~ADQ£P KlIMl'W- ~W, '

2. S.No. in the register of workmen employed

3. Nature of employment/Designation:

4. Wage rate (with particulars of unit in case of piecework):

5. Wage period:

6. Tenure of employment:

7. Remarks/ Date of Joining ,

0 2. /~{ll.c2.5J

Place: ~ o'f'A
Date: ot IV1- \ 1." '2 3

Signature ofthe contractor

lOIP ag e
 PERSOLKELLY India Pvt Ltd
(formerly known as Kelly Services India
Pvt Ltd)
Unitech Cyber Park
Unit No- 1202-1204, 12th Floor, Towe
r-C
Sector -39 Gurgaon
122002 Haryana
Email : Jnfo_i n@ persolkelly.com
website: www.persolkelly.co.J!).
CIN U74910KA2001PTC029Sl

Nomination Form
(Form-D)
1. Sh./Smt~ J ~ .~ ~ ..whose parti
culars are given in the statement given belo
my death before resuming work the balan w l here by enquire that in the eve~t of
ce of my pay due for the period of leave with
my nominee s mentioned as under. wages not avail ed of shall be paid to
2. Nomination made herein invalidates
my previous nomination.

S.No Name In Full Address in Full Relationship with Age of Proportion by whic
employee Nominee balance of pay will
shared

Statement
l. Name of the employee in Full :.. ... :.\?..~W.~E: .f .....K\).H.AA......~w . . . ....... . . . ....
Name of the Father :..... .. ...... . ... Q)~
2.
.~ K ~f \ .......F.fr.Y.................... ........................... .
3. Sex :.. ..... . .. .. .... . .. ...... ... ..... .. H~\.::~....... ....... ...... ........................ .................................... ..
.
4. Religion : .. .. ..... .. ..... .... .. .. .. . r\°;}.~.~.\J ........................................... ••·· •·· ..... •·· ··· •·
·········... ··· ·····
Whether Unmarried/Married/Widow/Wid
5. ower: .. ... .. \J.\Y..M.\r.R.~&P. ................... ..
6. Departme nt/Branch/Section where empl
oyed : ...... .... ..... ... ... ... ...... .... .. .. .... ......
...... .... ... .
7. Designation : .... .. .. .. ...... ..... ... ......
. ... .... ..... ...... ...... ... ... .. .... .. •••.. •••••. •.. ••••••••..
••••••••••.. ••.. •••••.. •••...
8. Category : .. ..... ..... ... .. .. .... .... ... .....
... ...
... .. ...... . ... ..... .. ... ... .. ...... .. .. ...... ......
..... ...... .. ... ..... ...... .. ... .
Date of appointment: ... .. ...... .. ...... ......
9. .. ... ...... ... ... ..... ....... .... ..... .. ... .. .. ....
.... ...... .... .... ... ...... . .
10. Wages : .... ..... ... ... ...... . .... ......
...... .. ...... ....... .... ... ...... ... .... .... ...
..... ..... ... ... ...... ... .... .. ...... .. .... ... ...
..
Perm anen t Address :

Vil! : ... .\(\\.G.ifH?-.ef.~.~..~.e.q.~ ··· P.O : ······K .t\ ~R ~~.~~.1-:-f..~P.....

Than a: ... .. ~~ Il \.~.O..t/....... ...... . District : .... .. l1.01fr............ ...... ........
Place :... .' 6 ~ ~·· ···· ········ ··· ······ Date: ..... ..... .... ... ..... ...... .... .... .. . .....
······ ··· ... ..
Sign atur e/Th umb of the employee
. . .
(Declaration by the witne ss)

Nom inati on signed/thumb-impressed

before me.
Nam e in Full & Address of the witn Signature of witness
ess

I. I.
2. 2.

Place :
Date :

-
11 I P a g e
 G
Q-
(formerly known as Kelly Services ln<11 ~
/')
Unitech c '<
Unit No-1202-1204, 12th Floor, l ~ .
Gu~v
Sector -39
WJJ PERS OLKELLY 122002 Ha
Email : lnfo_i n@persolkelly.
Website: www.persolkellv.co 1,
CIN U74910KA2001PTC~

Certificate by the employer

Certificate that the particulars of the above nomination have been verified and recorded in the establishme
nt.
Employer's Reference No: ........ .. .. .. .. .. .. .. .. .. .... .... .. ........ ... .. ...... ... If any

Date : Signature of the employer/Officer

Authorized
Add. Stamp of the factory
Acknowledgment bv the Employee

Received the duplicate copy of nomination on Form-D filed by me and duly certified by employee

""" ~ ~"' -~
u~ ~fthe employee

12 IP age
 PERSOLKELLY India Pvt Ltd
·a PIil Ltd)
(formerly known as Kelly Services In d 1
Unltech Cyber Park
Unit No- 1202-1204, 12th Floor, Tow er-C
Sector -39 Gurgaon
122002 Haryana
Email: info_ln@persolkelly.com
Website: w w w.persolkelly.co.1n
CI N U74910KA200 1PTC02951

FormF

PAYMENT OF GRATUITY ACT. [ SEE SUB-

RULE (1) of Rule 6] NOMINATION

~~: ...~ .~$.9~..tEt~.Y. ...·.~ .-.~

·························································...
[ I Give here name or description of the establishment with full address ]

I . Shri/Shrimati. .. 9..R~.8.EP. ....~1.JH..(\\-1......~ fW........................... .

[Name in the here]

Whose particulars are given in the statement below. I hereby nominate the person(s) mentioned below to receive the gratuity
payabl~ after my death as also the gratuity standing to my ccedit in the event of my death before the amount has be~om~ p~yable
or having become Payable has not been paid and direct that the said amount of gratuity shall be paid in proportion indicated
against the narne(s) of the nominee(s)

2. I hereby certify the person (s) mentioned is/are a member (s) of my fami ly 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.

I
(b) My husband's/father/mother/parents is/are not dependent on my husband.
I
,1 5. 1 have excluded My Husband from my family by a notice dated the .. .. ...... to the controlling authority in terms of the
I provision to clause (h) of section 2 of the said Act.
i 6. Nomination made herein invalidates my previous nomination.

NOMINEE'S

Name in full with full address Relationship with the Age of Proportion by which the
ofnominee(s) ( I) employee nominee gratuity will be shared (4)
(2) (3)

VJ:~(VV \.Cl\lrt
Y:ry~
>

\-(\-\~fl~~ ttt,-t' t, P-, ~h ~'1-\EXl {O"b---1 •

13 I P a g e
 0c
PERSOLKELLY 1 JQ-
/

(formerly known as Kelly Services lndJ /'JV

'<
Unitech c tt,,..
Unit No-1202-1204, 12th Floor, T ~~
Sector -39 Gu,
Wc!l PERSOLKELLY 122002 Ha
Email: info_ln@persolkelly.
Website: www. ersolkell .co.I
CINU74910KA2001PTC029S1

STATEMENT

I. Name of the employee infull ... ~e~.e...\<uM~••••••....···i~ . ............

··························.
2. Sex ..... ...... ..... ..fv.\~.L-,€;........................ •. ••••••••••••. •••••
3. Religion ..... ..... .......H~.u.......................................... ..................... .........

4. Whether unmarried/marriedfo~dow/widower.. .. .... ..\).tJ..M.&fl.P.:£6:1).. ·••··.. ···.. ···.. ·

5. Department Branch/Section where employed ............ ................ .... .. ... .. .. ..... .... •.. •" ..
6. Post held with Ticket No. Serial No. if any .. ... .. ............. ....... ... .. ...... .......... .. •••.. .. •• .. •·
7. Date ofappointment .......... ...... ... .... ..... ............ .... .. ...... ........ ... ..... ..... .. ...... ••••· •· · ..
8. Permanent address .. ....... ....... .. ......... ........ •·•··· ·•· ·• ·· ·• •.. . •·· ·••• •· ···· •··••· •···· ······· ···· ···
Village .. ~\\b\lf}.~$.ClO\l'.W-.Toana.. \(AJ:n-1.~bl\,[.Sub Division ..\(\\e:Q.~t)t)L{J1t(2.
"::«~~I.IU<l>'""''·~ ·· · '""·· ~w ~~ :i.~
Si~umb Impression
of the employee
Date ..... ....... ... .

Declaration by witnesses

Nomination signedflbumb impressed before me Name in full and full address of

witnesses

Signature of witnesses

Place:
Date ................ .... .. .... .

Certificate by the employer

Certified that the particulars of the above nomination have been verified and recorded in thi~ tablishm~t
I~~~\:'\
Employer's reference No, if any Signatur~ e employer/Officer authorized
Designation

Name address of the establishment

Date ...... .. ........ ... . or rubber stamp there of

Acknowledgment by the employee

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

Date .... ... .. ... ... .. ..... ..

~~~
Note: Strike out words/paragraph not applicable Signaro/eof the employee

14\ Pa ge

l
~ l
 . pvt Ltd
PE RSOLKELLV Ind ia
Ices India Pvt Ltd)
(form erly known as Kelly Serv . h Cyber park
Unitec wer-C
Unit No-1202-1204, 12t h Floo 39r, ~~rgaon
Sector ·
122002 Harya na
Email· Info in@persol kelly.com
: . ~ ·persolkelly. cQJ!!
w ebsite. 51
CIN U74910KA2001PTC029

New Form : 11 - Declaration Form

(To be retained by the emplayer for future reference)

EMPLOYEES' PROVID ENT FUND ORGANISATION

Employees' Provident Fund Scheme, 1952 (Paragraph 34 & 57) and
Employees' Pension Scheme, 1995 (Paragraph 24)

(Declaration person taking up Employmen in any Establishment on which EPF Scheme, 1952 and for EPS, 1995 is applicable)

1. Name of Member (Aadhar Name)

Father's Name Spouse's Name
2. c- tidcvhiP.« ,w{K;able)
3. Date of Birth (dd/mm/Y'f{Y)
4. Gender (Male/ Female/ Transgender)
S. Marltal status ? (Slnqle/Harried/Widow/Widower/Divon:ee)
(a) eMall ID
6.
(b) Mobile No (Aadhar Registered)
Whether earlier member of the Employee's Provident Fund
7· Scheme, 1952 ?
Whether earlier member of the Employee's Pension
8· Scheme, 1995 ?
Previous &nployment details ? (lfY~ 7 &Bdelails abcwe)
a) Universal Account Number (UAN)
b) Previous PF Account Number
9. c) Date of Exit from previous Employment? (cl,j/mmfyyyy)
d) Scheme Certificate No (If issued)
e) Pension Payment Order (PPO) (If issued)
a) International Worker Yes/~

b) If Yes, state country of origin (name of other country)

10.
c) Passport No.
d) Validity of passport (dd/mm/yyyy) to (dd/rrm/yyyy)
KYC Details : ( ~ set attested copieS d following KYCs) Must &-dose~ ~ for Ifie following OOQJTTients

a) Bank Account No. &. IFS Code G Lrnr:? ooo~ sig

11.
b) MOHAR Number
c) Permanent Account Number (PAN), If available

Aftu S.p 20:!.4 aa,n•d EPS

Arst EPf Member F1Bt Employment EPf Are you EPF Member If Yes, EPF Amount JfYe<, EPS(Pemlon)
IP•n1iion) Am ount Withdn-n
Enrolled Date Wages before 01/09/2014 Withdrawn? Amount W~awn? M fota .kJln cutn~mployu 7
~
12.
~ /No ~ /No wt/ No ~ /No

UNDERTAKING
1) Certified that the particulars are true to the best of my knowledge
2) I authorize EPFO to use my Aadhar for verlncation / authentication / eKYC purpose for service delivery
the present PF account.
)) Kindly transfer the fund and service details, Wapplicable, from the previous PF account as declared above to
(The transfer would be possible only Wthe identified KYC details approved by previous employer has been
verified by present employer using his Digital Signature

~~ 'J::\~
4) In case or changes In above details, the same will be lntimatod to employer at the earliest

Date:
~ eof Member
Place:

15 I P a g e
 G , V
PERS
(formerly known as Kelly Se (f.:
(

Unit No- 1202-1204, Q<.<J

('JI PERSOL KELLY 121
Sect
12
~
'I(/
Email: info_i
Website:
CIN U7

DECLARATION BY PRESENT EMPLOYER

A. Tu member l.1 JJM1./lllrs. ···-········ ·····
.. \
Lo
. . .... Ha,,o;• ed 0 0 • • • • . . • • •••••••• • • . •d hs bcc111llon
8. ed PF Number ·
,.,. 1M """°" "" wi;.,. nou memboo f EPF Scheme, 19l2 md
EPS. 199l: ((Post 111 .. mcal of UA N) The UAN oll'"tcd I · ) Pl Tick the Approprillc Option:
The KYC dcwlo of lhc Ibo,·, moabc< m 1M JAN daubac or he member II case

Have not been uploaded ::J Have been upload ed but not approved
C. _j Have been uploaded and approved wi th DSC
I.a aK the pc:non .-11 carhcr I mcabcr of [ PF Sdtcmc.
1952 a,d EPS 1995.
lJ l\c: KYC det.all of tbc lbon •ember ia the UAN d1tabee hn c been ippnn-ul
•ilh Di&ilil Signalurt Ccrtific:atc and rr1nsfcr rcqucsl has
been acncralcd on portal
Cllabhslun~ Aa the DSC of csubli.sbmen1 n DOt rq111cn:d •1tb EPFO. tltc member ha been iafonaed
IO rile physical cl aim (Fonn -13) for transfer of funds
from bi1 prc,·ious

Date :
~~~
Sig2 of Employer with Seal of Establishment

161 P a ge
 - • I Lt=' \ Al1~L- • '

fA PERSOLKELLY PERSOLKELLY India Pvt Ltd

(former ly known as Kelly Services In d.,a Pvt Ltd)
Unitech Cyber Park
Unit No-120 2-1204 , 12th Floor, Tower- C
sector -39 Gurgao n
122002 Haryana
Email: info_ln@ persolk elly.com
Website: www.p ersolke lly.co.in
CIN U74910KA2001PTC0295l

DECLARATION FORM
Form 1
To be filled bv em lovee after rcadin
(A) INSURED PERSON'S PARTICULARS
instruction overleaf. Two Postcard size hoto a hs to be
I. Insurance No. attached with the fonn
2. Name (Bl EMPLOYER'S PARTICULARS
In Block ca ital) Em lo cr's Code No.
3. Father's /
Date of Appointment
Husband's Name
Name & Address of the cm lover
Date ofBinh

Present Address
Permanent Address l .In case o any perv,ous cmp oymcnt p ease
up .
the details below: -
~\-\(\-'fl>O \<A ('-\b ~l\\..'- I ~\¼;;Rf\ a) Previous ins. No.
(lf¼oi, (, POP I K~'\A: b) Em lo cr's Code No.
Pin Code c) Name & Address of the employe r with
Pin Code Telephone No & E-mail Address
Telephone No
&E-mai l c ep 1one
No & E-mail Address
Address

Branch Office
Dispensary
C. Details of the Nominee u/s 71 of ES I Act 1948/ Rule
56(2) of ES! (Central Rules, 1950 for payment of cash benefit
in the event of dcatlt

Vr.S\-1
I Hereby declare that the paniculars given by me are correct
family within 15 days of such change. to the best ofmy knowledge and belief, I undenake to intimate
the corporation any changes in the membership ofmy

Counter Signature by the employer

Signature With Seal
(D) FAMILY PARTICULARS OF INSURED PERSON

Sr No. Date of Relationshi Whether res, mg

Name I O state p ace o
Binh/ age as pwith with
himlher? Residence
on date the Town State
of form Yes No
Employee
fi in

3
4
5
6
7
8

----- - ----- -- -- ----- - ---- -- --- ----- - --- --

Name

Insurance No.

Branch Office Dispensary

Employer's code No.&

Addrcss

Validi : Date : Si ature/T.J ofl.P. Sienature ofB.M. with seal

17 I P a g e
 PERSOLKELL~
1 q-:J
(formerly known as Kelly Services In /') <(/
Unitechc "(.
Unit No-1202-1204, 12th FIOQ,, l ~
WJ.1 PERSOLKELLY Sector -39,..
...u,
122002 lia
Email: lnfo_ln@ persolkelly,
Website: www. ersolkell .
0
Cl N U7 4910KA2001 PTC02g~
1

ISTRUCTIONS

t Submission offonn-1 is governed by regulalion

11 & 12 ofESI (General) Regulations 1950

2
(i)a SJ)Ouse (ii) a minor legitimate or adopted child
deperdent upon the J.P.; (iii) a child who is wholly
dependent on the earning of the I.P. and who is
(a) receiving education, till he or she attains the
(b) an unmanied daughter, (iv) a child who is infinn age of 21 years
by reason of any physical or mental abnormality
and is wholly deperdent on the earnings of the or injury
I.P. so long as the inlinnity continues; (v) depende
(please see Secrion 2 clause 11 of the ESI Act 1948 nt pan:nts
for details) .

3 Identity card is Non· transferable.

4 Loss o(ldentity card be reported to the Employ

immediately. er/ Branch Manager
5 Submission of false information al\racLS penal action
under Section of84 ofESI Act, 1948.
6 This form duly filled in must re.ich the concern
ed Ilranch Office within IO days of appoimmenl
&S ofESI Acl. apinsl employer. of an Employee. Delay altraCIS Penal action under
Sedion

7 As an lnsURd person
you and your dependent family members an: entitled
to full medical care from today
itsel ( The other
benefit

in cash include (l) Sickness benefit (2) Temporary

disablement benefit (3) Permanent disablement benefit
Dependents Benefit and (5) Maternity benefit (incasc (4)
contnbutory conditions. of women employees subject to fulfillment of

8 For more details please contact website ofESIC

Office. at www csjc org in or contact Regional office or
. Branch

For Branch Office Ust Only

l. Date of allotment oflns. No

2. Date of issue of TIC

3. Name / No. ofDisp

4. Whether n:ciprocal Medical

arrangements involved? If yes,
please indicate

Signature ofBranch Manager

Date ofBirth! Whether residin~ with lf'NO' state place of

Sr No. Name him!be(•
o~-, as on datt R~d1.:ncc
of form fillin~
t
2
,
nr,w \l mm n
'fl 1.1'\ ~ \1·M"'"
K:EN ' '
~1/o illc? lt
,,,,\ M\
I
lf,V\
l, l
I
.
voi. .
''"·
Yos No Tow
~. State

('J..t<H ,
.
.

18\P a ge
 I

I PERSOLKE LLY India pvt Ltd

I India Pvt Ltd)
(formerly know n as Kelly serv ces h Cyber Park
Uni tee C
rJJ PE RSOLKELLY Unit No- 1202-1204, 12th Floor,
rower-
secto r -39 Gurga
on

122002 Ha rvana
Email: lnfo_ln@persolkelly.co:
Website: www.persol kelly.co1
CIN U74910KA2001PTC02 95

Address• ~t\~\<j) p
(v1~~der •

NEW TAX REGIME OPTION - YES or NO

NO

• PAN of L.\NDLORD IS MUST IF TOTAL RE NT IS MORE THAN 100,000 PER ANNUM. WITHOUT PA.N, HRA EXEMPTION WILL NOT BE PROVIDED
UNDER SECTION 10 & 17
2 Month Rs. Total
-Rs. Month
Apr-23 Oct-23
May-23 Nov-23
I) House Rent U/s 10 ( 13A) Jun-23 Dcc-23
lul-23 Jan-24
Aug-23 Fcb-24
Scp-23 Mar-24
.UNDER SECTl~N 24B

Housing Loan lniercst - UIS 24B (Attach Fonn Rcstricied up to Rs.2,00,000 if the loan taken after 1-4-99, Rs 30,000 ifit is prior to 1-
12 C along with Interest Certificate) 4-1999

Let Out property - No Restriction- Calculation

need to be rovided
UNDER SECTION 80CCE (DEDUCTIONS UNDER .CHAPTER VI A- MAXIMUM LL°'111'. IS 1;50,0001- OF SECTIONS SOC and S0CCCJ
Li fc lusurancc
Eduction Fee (Only Tuition
Fee
Public Provident Fund
Deferred Annuity
Housing loan principal repayment
Rental Income(-) Municipal Taxes (-)30% Maintancncc (-) interest on borrowed
ca ital
Life Insurance Premium paid by an employee, on his life & dependents (Min 2 year
Plan
Any payment towards any development fees or donation or payment of similar nature
will not be cli iblc
PPF • Photocopy of the Passbook & Copy of the deposit slip
Deferred A1muity (Non-Conumutablc)
Condition has been laid that in case the property is transferred before the expiry of 5
years from the end of die Financial year in which possession of such property is
obtained by him, the aggregate arnowlt of deduction of income so allowed for vwious
years shall be liable to tax in that year. Also if Joint owner then 50% nemplion will
be applicable

Subscription to equity shares/debentures forming part of w1y approved eLigible issue of

Approved Debentures & Equity Shared
capital made by a public compw1y or public Finw1cial institutions

Rural Development Bonds ofNABARD Notified Bonds of National Bwtk for Rural Development
National Saving Certificaie National Saving Certificate Deposit (NSC)
Post Office Deposit Scheme Payment made as five year time deposit in an account under the Post Office

Post Office Saving Sum deposiied inl5 years accowtt of Post Office Saving Scheme

Fixed Deposit with scheduled Bank Fixed Deposits with scheduled Bank for 5 yrs or more (Photocopy required)
Accrued interest (which deemed as reinvested) is also qualified for w1y year (except for
NSC lncerest last car
Mutual Fwid / ULIP Unit Li1tked lnsurw1ce Plw1 (ULIP) ofUTI/ LIC Mutual Fwid (Min 5 Years Plan)
Mutual Fund Subscription to units of a Mutual Fund notified u/s 10(23D)
The premium must be deposiied to keep in force a contract for an wmuity plw, of the
Section 80 CCC UC or any other insurer for receiving pension from the fund

IO I \I. l '\llrl{ SI ( 110'\ 80( ( I: -

UNDER SECTIONS SOD. 80DD, S0DDB, SOE, 80EE,'SOG, ~OC_CFi ~0CCG, sou ETC (UNDE~. CIB.PTERVI-A) .,
Contribution towards NPS by employee with max limit of
SEC S0CCD (IB) NPS INR.50000/
-
Rajiv Gandhi Equity Savings Sch_eme • Lock in period is 3 Yrs and gross income docs not exceed 12
SEC 80CCG lacs (50% is applicable with maximum of25000/=)

9IPage
 PERSOLKELLY India"" '
(formerly known as Kelly Services India Pvt~
--
WJl PERS O LKELLY Unitech Cyber Pa~
Unit No-1202-1204, 12th Floor, Tower-c
Sector -39 Gurgaon
122002 Haryana
Email: info_ln@persolkelly.com
Website: www.persolkelly.co.in
CIN U74910KA2001PTC02951

25,000 for self and Family+ 5000 if parent covered .

SEC SOD For super senior citii.en (80 year.; and above), if
NO payment has been made to keep in force an insuranc
e on the health of such person, as does not
exceed INR. 50,000/= shall be allowed as deduction under
this section (bills required)
Parents covered (Yes/No)= >
I Whether Parents Sr Citizen (Yes/N o)=> I
SEC S0DD Medical Treatment of Dependent suffering from Pennane
Hospital & Selfdeclaration1 nt Disability (Certificate From Govt.

SEC S0DDB Deduction u/s. S0DDB for expenses incurred on treatmen

t of certain critical illnesses upto Rs I lakh
in respect of all senior citizens from existing Rs. 60,000
Recognised Hospital) / 80,000. (Medical Cerlilicate from
SEC SOE
Repaymenl of Higher Educational Loan (Only Interest
amounl is eligible)
SEC 80G
Employee can claim while fiHng lhe individual return
SEC BOTTA Exempt Savings Bank Interest Max Rs.10000/- (Total
lnrerest amounl should declare in row no: 58).
-
For Senior Citizen {60+ Yrs of aue1
,,
Interest income of senior citiuns (60-+years of age) on
SEC S0TTB deposils wilh banks and posl offices up 10 Rs.
50,000/- will be exempt u/s S0TTB and no TDS shall
194A. be deducled on such income, under section

SEC SOU
Pennanent Physical Disability (Personal) (Certificate
from Govt. Hospira! & Self declaration)
- , ..
PRI \ IOL S E\IPLOY\11 '.\l S \ I \RIIS IS \I •\RY
I \R'.\ l ll I RO\! Ill II ~ 2112 1 111 1 ll \ 11 01 JOl'.\l '.\
G I'.\ PERSOLKl"I LY)
ATTAC H PHOTOCOPY OF FORi\1' 16 OR
SALARY CERTIFICATE FROM -PREVIOUS EMPLO
. YER FOR FY 2021-22 WITH FORM 128. (MAND
NEW JOINE_ ATORY FOR ALL
E JOJ,NED A_FfER !ST APRIL 2021)
Previous Employer Income As per Fonn '
16 or Salary Certificate / Fonn
12 B
As per Fonn
-
Previous Employer PF 16 or Salary Certificale / Fonn '•

12 B
Previous Employer PT As per Fonn 16 or Salary Certificate / Fonn
-
12 B
As per Form
- I
Previous Employer Income Tax Deducted 16 or Salary Certificate / Fonn
12 B
-
OTHER INCOMES
~-
Income from Savings Bank
. ,.
- '
interest Bank and Post Office '
Income other than Savings
Bank interest I Any other income which is taxable
·-
..
'
lfany Others Please Specify I '--

• ·;;::
,
',',.'': "'.~

DIT I \RA 110'.\

I do hereby declare that whatever stated above is true

and correct to the best of my knowledge and belief an_d
also undertake to indemnify the company for any loss
arise in the event of the above mfonnabon bemg mcorrec / liability that may
t.

•PAN IS MANDATORY . IF PAN IS NOT PROVID

ED. DECLARATIO N WILL NOT BE
CONSID ERED.
• LA NDLORD PAN IS MUST IF AGGREGATED
RENT PAID OVER I LACS FOR
·
F"
•
2023-24
• Indicate s Mandatory fields

Place :
~"~~
Date :
~ Employee's Signature

20 IP a g e