Joining Form

Name Designation
Department Location
Employee ID Date of Joining

Head Office Fitelo E-190 Sector -74, Industrial Area, Sahibzada Ajit Singh Nagar, Punjab – 140308

Sl. Documents
No. Particulars Submitted (Yes/No Remarks
1. Joining Form
2. Form-11 (PF-UAN), Form – 2
3. Form-F (Gratuity)
4. Details For EPF and ESIC
5. Signed and Accepted Offer Letter copy
6. Signed Resume
7. Academic Testimonials (10th, 12th, Graduation)
8. Professional Certifications Degree documents (If Any)
9. Technical Certifications documents (If Any)
10. Passport Size Color Photographs – 4 Nos.
11. Identity Proof (Aadhaar Card, Pan Card, Driving
License, Passport, Ration Card, Voter Card etc.)

12. Bank Account Details (Canceled Cheque/ Passbook)

13. Residence Proof (Permanent Address)
14. Signed copy of Resignation Letter
15. Offer/ Appointment Letter and Pay slips for last 3
months of Previous Organization
16. Resignation Acceptance Letter from the Previous
Organization

17. Experience /Reliving Letter from the Previous

Organizations

18. Income Tax Declaration for Tax Deductible employees

I do hereby certify that all Documents mentioned above are submitted by employee and filed in
employee’s personal file.

For Fitelo

(Auth.Person from People Function Team)

 JOINING DOCUMENT
Please Paste
recent passport
size photograph

Personal Details
Name (in full) Date of Birth

Birth Place Height/Weight

Blood Group Age
Disability If Yes, details

Languages Proficiency
Email Id (personal) Marital Status;
Spouse Name:
If Married,
Mobile Number
No. of children
Nationality Religion
Educational Background
UG, Graduation, PG & Specialization Grade University & Year of
diplomas if any. attained/ % City completion
PG
Graduation /Diploma
10+2
Metric
Prior Experience (starting from the latest)
Designation Department Company City Tenure
/ Function (Name and size) (in years/ months)
 Address details
Present Local
Address Contact No.

Permanent Permanent
Address Contact No.

Family Details
Father's Full Name Age

Occupation Current Work

Status
Father’s Contact No. Emergency
Contact No.
Mother’s Maiden Name Occupation
Brothers/Sisters Current Work Educational Marital Status Residing In
(Name) Status Status

I hereby declare that all the information furnished above is true to the best of my knowledge and belief. I
will do all my duties to the best of my ability while following all the code of conduct of the company and
maintaining required level of discipline by the company.

Date: Place:

Name:

Signature:
 Additional Information

Employee Name Name ( As per

(As on Aadhar
passbook/Cheque)
Card)
Father Name Bank Name

Date of Birth Branch (location)

Type of Account :
Marital Status (Saving, Salary,
Current etc.)
Aadhar No. A/C No.

UAN (Previous) IFSC:

ESIC No. MICR:
(Previous)
Mobile No. Pan No.
(To be register)
Family Details(ESI Enrollment)
Family Name Date of Birth Aadhaar No. Address

Father Name

Mother Name

Brother/ Sister

Brother/ Sister

Spouse Name

Child 1 Name

Child 2 Name

Name…………………………………………………… Date……………………………………………………..

Signature……………………………………………..
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 ?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. 9- fu;kstd dh dwV la[;k
Employer's Code No.
2- uke ¼Li"V v{kjks esa½ 10- fu;qfDr dh rkjh[k fnu eghuk o"kZ
Name in block letters
Date of Appointment Day Month Year
3- firk@ifr dk uke
Father's/Husband's Name 11- fu;kstd dk uke vkSj irk@Name & Address of the Employer
4- tUe dh frfFk fnu eghuk o"kZ 5- oSokfgd fookfgr@ __________________________________________________
Date of Birth 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 8- LFkk;h irk@Permanent Address ¼d½ fiNyh chek la[;k
______________________ ______________________ (a) Previous Ins. No.
______________________ ______________________ ¼[k½ fu;kstd dwV la[;k
______________________ ______________________ (b) Employer's Code No.
fiu dksM fiu dksM
Pin Code Pin Code ¼x½ fu;kstd dk uke o irk
VsyhQksu uEcj@bZ&esy 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

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.

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

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; QksVks ds fy, LFkku
vkS"k/kky;
Branch Office Dispensary (Space for photograph)

fu;kstd dh dwV la[;k o irk

Employer's Code No. & Address

oS/krk
Validity
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
 vuqqqnsss'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.

dssoys 'kk[kk dk;kZZy;Z esasasa izz;kzsx gssrsqqq

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
 (FORM 2 REVISED)

NOMINATION AND DECLARATION FORM FOR UNEXEMPTED/EXEMPTED ESTABLISHMENTS

Declaration and Nomination Form under the Employees Provident Funds and Employees Pension Schemes
(Paragraph 33 and 61 (1) of the Employees Provident Fund Scheme 1952 and Paragraph 18 of the Employees
Pension Scheme 1995)

1. Name (IN BLOCK LETTERS) : _______________________________________________________________________________

Name Father’s / Husband’s Name Surname

2. Date of Birth : ___________________ 3. Account No. ___________________

4. *Sex : MALE/FEMALE: ______________________ 5. Marital Status ________________________________________

6. Address Permanent / Temporary : _____________________________________________________________________________

________________________________________________________________________________

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.
If the nominee is minor
Name of the Address Nominee’s Date of Total amount or share of name and address of the
Nominee (s) relationship with Birth accumulations in guardian who may receive
the member Provident Funds to be the amount during the
paid to each nominee minority of the nominee

1 2 3 4 5 6

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.

Strike out whichever is not applicable Signature/or thumb impression

of the subscriber

PART – (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 premature death in service.

Sr. No Name & Address of the Family Member Age Relationship with the member

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

Certified that I have no family as defined in para 2 (vii) of the Employees’s Family Pension Scheme 1995 and should I acquire a
family hereafter I shall furnish Particulars there on in the above form.

I hereby nominate the following person for receiving the monthly widow pension (admissible under para 16 2 (a) (i) & (ii) in the event
of my death without leaving any eligible family member for receiving pension.

Name and Address of Date of Birth Relationship with member

the nominee

Date ___________________

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.

Date : _____________________ Signature of the employer or other authorised officer of

the establishment

Place :
Name & address of the Factory /Establishment
Date :
 FORM 'F'
See sub-rule (1) of Rule 6

Nomination

To,
(Give here name or description of the establishment with full address)

I, Shri/Shrimati/Kumari
(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 the Age of Proportion by which
address of nominee(s) employee nominee the gratuity will be
shared
(1) (2) (3) (4)
1.
2.
3.
So on.

Statement
1. Name of employee in full
2. Sex
3. Religion
4. Whether unmarried/married/widow/widower
5. Department/Branch/Section where employed
6. Post held with Ticket No. or Serial No., if any
7. Date of appointment
8. Permanent address:
Village Thana Sub-division
 Post Office District State
Place: Signature/Thumb-impression of the

Employee
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:

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.

Date: Signature of the Employee

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