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BOS eG Kul Wo DoERts Dow God SmELOtLIEN GoKLoD
tea & faq aha watts Aah afte a weqe fare are t
‘TO BE SUBMITTED IN DUPLICATE IN RESPECT-OF EACH PENSIONER ELIGIBLE FOR PENSION
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ere sabre ta ar R/O FT|
Coss oof Pesione nchishe pacman saleltumb npreion
1) eyo ee Name oft Marbar
2) abo6. emyoute. (oA. wrt JERR Neti
3) Sesioaae,AUMTA/Name ote Pennoner
4) 6g /azSe nfm ranararuabands ibe
9) Sfosssfin/sen
6) wb fat Nacoaty
2) sepa regs
8) aston
9) sys ge te eon some
Porn! ieiceon mar ens
10) bess cen wren scent 83 Fe
Specmen Sorat of Perioner
11) deseo dupes (seuons Bs ecoroe (Lope) ooasst
(ren Fre eter err aA) ad eh Be
(Onin te cae of irate clemar (Pesione) Lot Mand Finger meson
esse wage cacao sone
1 a cd wa
THM moots RNG sua
02 fe ace ‘FT signature
Seftifone : seate sy wpmo Se, wororane
reciente ater Soe, wee
woth Aten, tory fh So
& doo a8om Sebseosss:ano jain Frm met Py Cortes hat =
1 Sebo a, 8 oe ts bb Ba,
Asia ea te, 1980 8 ante fe a8 el
‘a ot ranean under Enloyens’ Pons Chee, 855
2) Daina pad om dae ct enving
testo of propeang sca hve ma ocon
‘rpyec ney eve estaba,
2) eos tw on mete rgd
Foon ea Ree ee ee te wh
“The parca ghonin a appesin eve xox,
cap waa seat 6a So Pst
NE ae DECLARATION
PARTICULARS OF THE MEDIER,
8) Nome of the member
) Fathers Husband's Name
9) PRAICNe.
Scheme Certificate No,
6), Date of bith ofthe acne
(As per Scheme Cerificate)
1) Marital Status ofthe Member: Un-saried Married Widow/Widower
‘CRRCTEICATI ROM MEMBER FOR MEMBER PENSION
1, certify that Ihave neither employed pir to jong nor taken any
scaployment afer the date of my exit from the preset secvcr to tl date of tie
‘pplication ia any covered establichmeat under the Employees Provident Pund &
Mleesllncous Provisions Act, 1982.
Date:
Place:
Sigaatuselssab inpresson of claimant
CERTINNCATE FROM WIDOW/CLAIMANT FOR WIDOW PENSIONICHILDREN
TENSIONORPIAN PENSION
8) Applicants Nema (Widew/Widoweruedias)
1, uy tat the devoted member hs iter employed peor tooling nor
{sien eny employments cats of tis eit ftom thcervic tol ais of is appicton
in any covered esublishent under the Employees Provident Fuids & Miscelseais
Provisions Act, 1952. Lbary- cleo not cum Pecslouay Beaeis excep fom tis
‘elisheeot en also wil not ln in fut fom eny oi covered estabiatie:t dar
the Binpoyees rovieat Fund & Mi ProvisoasAc 1932
Signaturethumb impression ofchimant
