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Form 11 Revised Format

This document is a declaration form for an employee taking up employment in an establishment where the Employees' Provident Fund Scheme and/or Employees' Pension Scheme applies. The form collects personal details of the employee such as name, date of birth, gender, contact details, education level, marital status, and whether the employee was previously a member of the provident fund or pension scheme at another establishment. The employee declares this information and any previous member details to be retained by the employer.

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Parth Upadhyay
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© © All Rights Reserved
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763 views

Form 11 Revised Format

This document is a declaration form for an employee taking up employment in an establishment where the Employees' Provident Fund Scheme and/or Employees' Pension Scheme applies. The form collects personal details of the employee such as name, date of birth, gender, contact details, education level, marital status, and whether the employee was previously a member of the provident fund or pension scheme at another establishment. The employee declares this information and any previous member details to be retained by the employer.

Uploaded by

Parth Upadhyay
Copyright
© © All Rights Reserved
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Declaration Form

(To be retained by the Employer for future reference)

Employees Provident Fund Organization


THE EMPLOYEES PROVIDENT FUNDS SCHEME, 1952 (PARAGRAPH-34 & 57)
&
THE EMPLOYEES PENSION SCHEME, 1995 (PARAGRAPH-24)

DECLARATION BY A PERSON TAKING UP EMPLOYMENT IN AN ESTABLISHMENT ON WHICH EMPLOYEES PROVIDENT FUND SCHEME,
1952 AND/OR EMPLOYEES PENSION SCHEME, 1995 IS APPLICABLE.
(PLEASE GO THROUGH THE INSTRUCTIONS)

1) NAME (TITLE) K I R T I G E E T E Y
MR . MMRS.
S
(PLEASE TICK)
.

2) DATE OF BIRTH D D M M Y Y Y Y
0 5 0 9 1 9 9 1

3) FATHERS/ MR . L A T E S H R I A S H O K G E E T E Y
HUSBANDS NAME

4) RELATIONSHIP IN RESPECT OF (3) ABOVE FATHER HUSBAND


(PLEASE TICK)

5) GENDER MALE FEMALE TRANSGENDER


(PLEASE TICK)

6) MOBILE NUMBER 9 9 7 0 9 2 2 8 1 2
(IF ANY)

7) EMAIL ID (IF ANY) k i r t i g e e t e y @ g m


a i l . c o m

8) WHETHER EARLIER A MEMBER OF THE EMPLOYEES PROVIDENT FUND SCHEME, 1952?


(PLEASE TICK) YES NO
9) WHETHER EARLIER A MEMBER OF THE EMPLOYEES PENSION SCHEME, 1995?
(PLEASE TICK) YES NO
IF RESPONSE TO ANY OR BOTH OF (8) & (9) ABOVE IS YES, THEN MANDATORILY FILL UP THE PREVIOUS EMPLOYMENT DETAILS
AT (10,11&12):
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A. PREVIOUS EMPLOYMENT DETAILS
10) THE DETAILS OF THE UNIVERSAL ACCOUNT NUMBER (UAN) OR PREVIOUS PF MEMBER ID:

UAN
OR
PREVIOUS PF MEMBER ID REGION CODE OFFICE CODE ESTABLISHMENT ID EXTENSION ACCOUNT NUMBER

11) DATE OF EXIT FOR PREVIOUS D D M M Y Y Y Y


MEMBER ID (DD/MM/YYYY)

12) (A) IF SCHEME CERTIFICATE ISSUED FOR PREVIOUS EMPLOYMENT, THEN SCHEME CERTIFICATE NUMBER:
(B) IF PENSION PAYMENT ORDER (PPO) ISSUED FOR PREVIOUS EMPLOYMENT, THEN PPO NUMBER:

B. OTHER DETAILS

13) INTERNATIONAL WORKER YES NO


(PLEASE TICK)

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

13(B) PASSPORT NUMBER

13(C) PASSPORT VALID FROM


D D M M Y Y Y Y

To D D M M Y Y Y Y

14) EDUCATIONAL NON- SENIOR POST TECHNICAL/


ILLITERATE MATRIC GRADUATE DOCTOR
QUALIFICATION MATRIC SECONDARY GRADUATE PROFESSIONAL
(PLEASE TICK)

15) MARITAL STATUS MARRIED UNMARRIED WIDOW/ WIDOWER DIVORCEE


(PLEASE TICK)

16) SPECIALLY ABLED YES NO IF YES, TICK THE CATEGORY


(PLEASE TICK) LOCOMOTIVE VISUAL HEARING

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