Declaration and Authorization

I hereby authorize Essar Oil And Gas Exploration And Production Limited (or a third party agent appointed by the
Company) to contact any former employers as indicated above and carry out all Background Checks not
restricted to education and employment deemed appropriate through this selection procedure. I authorize former
employers, agencies, educational institutes etc. to release any information pertaining to my
employment/education and I release them from any liability in doing so.

I confirm that the above information is correct to the best of my knowledge and I understand that any
misrepresentation of information on this application form may, in the event of my obtaining employment, result in
action based on company policy.

Signature:

Name: Adil Mirda

Date: 14/06/2023
 EXPENSE REIMBURSEMENTS FORM

EMPLOYEE NAME : Adil Mirda COMPANY : Essar Oil And Gas Exploration And
Production Limited

SAP CODE : 30002405 DIVISION / DEPT. : Exploration

GRADE / LEVEL : M-9

Kindly reimburse the following expenses incurred by me in connection with Company's work:

S. No Date Particulars Purpose Amount

TOTAL

Rupees in
words:

Approved by :
___________________

Signature of Employee Name :

Date :

Date : 14/06/2023 Signature :

 Composite Declaration Form -11
( To be retained by employer for future reference )
EMPLOYEES' PROVIDENT FUND ORGANISATION
Employees' Provident Funds Scheme, 1952 (Paragraph 34 & 57 ) &
Employees' Pension Scheme, 1995 (Paragraph 24)
(Declaration by a person taking up employment in any establishment on which EPF Scheme, 1952 and /or EPS, 1995
is applicable)

1 Name of the member-As per Aadhar Adil Mirda

2 Employee Number : (Present Establishment) 30002405

Essar Oil And Gas Exploration And Production

3 Company Name : (Present Establishment)
Limited

4 Father Name Firoj Mirda

5 Husband Name

6 Date of Birth : ( DD/MM/YYYY ) 11/09/1999

7 Gender : (Male/Female/Transgender) Male

Martial Status:
8 Single
(Married/Unmarried/Widow/Widower/Divorcee)

a) Email ID: [email protected]

9
b) Mobile No : 91-7003743019

Present employment details:

10 Date of joining in the current establishment 12/06/2023
(DD/MM/YYYY)
KYC Details:(attach self-attested copies of following
KYCs)

a) Bank Account No & Name of the Bank :

11
b) IFS Code of the Branch :

c) AADHAR Number
 d) Permanent Account Number(PAN), if available

Whether earlier a member of Employees' Provident Fund

12 Scheme 1952 (Mandatory)
YES/NO

Whether earlier a member of Employees' Pension

(Mandatory)
13 Scheme , 1995
(If Yes, please
YES/NO
attached E-passbook)
Previous employment details: [ if Yes to 9 AND/OR 10 above ] - Un-exempted

Establishme Universal PF Account Date of joining Date of exit Scheme PPO Non
nt Account Number (DD/MM/YY (DD/MM/YYY Certificate Number (if Contributory
Name & Number Y) Y) No. (if issued) Period
Address issued) (NCP)
Days
14

Previous employment details: [ if Yes to 9 AND/OR 10 above ] - F or exempted Trusts

UAN Date o f joining Date of exit Scheme Non

Name & Certificate Contributory
Member EPS (DD/M M/YYY) (DD/MM/YYY
Address of the Y) N o. (if Period (NCP)
A/c Number issued) Days
15 Trust

a) International Worker

b) If yes, state country of original (India/Name of other

country)
16
c) Passport No.

d) Validity of passport [(DD/MM/YYYY) to

(DD/MM/YYYY)]

17 e) Qualification

Bank Cancel Cheque/Aadhar Card and Pan

18 KYC Details:(attached self-attested copies of KYCs)
Card ---(Mandatory)
 UNDERTAKING

1) Certified that the Particulars are true to the best of my Knowledge.

2) I authorize EPFO to use my Aadhar for verification / e KYC purpose for service delivery.
3) Kindly transfer the funds and service details, if applicable if applicable, from the previous PF account as
declared above to the present P.F Account (The Transfer would be possible only if the identified KYC
details approved by previous employer has been verified by present employer.
4) In case of changes In above details the same Will be intimate to employer at the earliest.

Date: 14/06/2023
Place: Durgapur

Signature of Member

DECLARATION BY PRESENT EMPLOYER

A. The member MR. Adil Mirda has joined on 12/06/2023 and has been allotted PF
Number…………………………...........................and
UAN............................................................................................
B. In case person was earlier not a member of EPF Scheme ,1952 and EPS,1995:
• Please tick the Appropriate Option:
The KYC details of the above member in the UAN database
Have not been uploaded
§
Have been uploaded but not approved
§
§ Have been uploaded and approved with DSC/c-sign
C. In case the person was earlier a member of EPF Scheme ,1952 and EPS, 1995:
• Please tick the Appropriate Option:
$ The KYC details of the above member in the UAN database have been approved with digital
signature Certificate and
transfer request has been generated on portal.
$ The Previous Account of the member is not Aadhar verified and hence physical transfer form shall be
initiated.

14/06/2023
Signature of Employer With seal of Establishment
* Auto transfer of previous PF account would be possible in respect of Aadhar verified employees only, Other
employee s are requested to file physical claim ( Form-13 ) for transfer of account from the previous
establishment.
 FORM OF APPOINTMENT OF BENEFICIARY

(NOMINATION)

EMP.CODE - 30002405

Mobile No - 91-7003743019

THE TRUSTEES,
Essar Oil And Gas Exploration And Production Limited
EMPLOYEES GROUP GRATUITY SCHEME,

Dear Sirs,

I, Adil Mirda, a member of Essar Oil And Gas Exploration And Production Limited, Employees Group
Gratuity Scheme, hereby agree to abide by Rules of the said Scheme and do also hereby appoint in terms of
the Rule 18 of the Rules the Beneficiary/Beneficiaries /Nominee/s mentioned hereunder to receive the benefits,
payable under the Scheme, in the event of my death before the amount become payable has not been paid.

I hereby direct that the benefits under the scheme payable in respect of me, shall be paid to the said
Beneficiary/Beneficiaries/Nominee/s in proportion indicated against their respective names as given below:

Sr. Name in full with full Relationship Age of the Proportion by which
No Address of with the Nominee/s Gratuity (total
. Nominee/s Member Benefi-ciary/ies benefits)
(Employee) will be shared by
Beneficiary/ ies Nominee/
each
beneficiary

1.

2.

3.

I hereby certify that the person (s) mentioned herein above is are my wife /children/ lawfully adopted
child/dependent parents/husband.
I hereby declare that I have no family and should I acquire family hereafter the appoint of Beneficiary/
Nominee should be deemed as cancelled .
My father /mother /parents /sister (s) /minor brother (s) is are not dependent on me.
My husband's father /parents is/are not dependent on me.
I also declare that this appointment of Beneficiary/ies /Nominee/s made herein shall have the effect of my
revoking the appointment of Beneficiary /ies/Nominee/s made by me earlier.

I give below the particulars about myself.

Full Name - Adil Mirda

Religion - Islamic
Date of Birth - 11/09/1999
Sex - Male
Marital Status - Single
Father's Name - Firoj Mirda
Husband's Name: (For Married women only) Firoj Mirda
Permanent Address :
Budge/B, Pock Pari 20A, Dharmatala Rd, Kalikapur Uttar Para, Budge Budge, Kolkata, West Bengal 700137
Kolkata India

Signed at _______________this______________ day of_____________20____.

SIGNATURE OF MEMBER

WITNESS BY:

1. Signature:______________________________

2. Name :______________________________

3. Address :_______________________________
 _______________________________

1. Signature:_______________________________

2. Name :_______________________________

3. Address :_______________________________

_______________________________

Certified that the above appointment of Beneficiary/Nominee has been signed by Shri / Shrimati
__________________________________________ before me after he/she has read the entries, the entries
have been read to him/ her by me and that the said appointment of Beneficiary /Nominee is recorded under the
Scheme on______________________

_______________
Signature of Trust
For self and Co-Trustees of Essar Services India Private Limited.
Employees Group Gratuity Scheme.

Note :

1.Where an Employee Member has a family at the time of appointing a Beneficiary/Nominee, the Nomination
should be made in favour of Members of his family only. Any Nomination made by such employee in favour of
any other person not belonging to his family shall be invalid.

2. An appointment of Beneficiary /Nominee made by the Member may be changed at any time, after giving a
written notice to the Trustees of his intention to do so. If the Nominee predeceases the Member(Employee), the
interest of the Nominee shall revert to the Member (Employee) or his estate.
 DECLARATION - DEPENDANTS COVERED BY GROUP HEALTH INSURANCE POLICY

I. Name of the Employee - Adil Mirda

Designation - GT Geoscientist

Emp. Code - 30002405

Company - Essar Oil And Gas Exploration And Production Limited

Function/Dept - Exploration

Location - Durgapur

Level - M-9

Date of Birth (DD/MMM/YYYY) - 11/Sep/1999

II. Dependant Spouse details (if not covered separately in his/her own organization)

Date of Birth Age (in Relationship

Name of the Dependant (Spou Gender
(DD/MMM/YYYY) years) with Employee

(DD) (MMM) (YYYY)

III. Name of Dependent Children (Not married and not employed)

Date of Birth Age (in Relationship

Name of the Dependant (Child Gender
(DD/MMM/YYYY) years) with Employee

NOTE: The Insurance benefit is not extended to spouse who are working and are covered in similar benefit scheme in their
own organization. For more details please refer to the Group Health Insurance Policy on' Third Eye'.

Please note the policy covers only the first two children up to the age of 25 years.

I declare that the above information is true and correct.

Date : 14/06/2023

____________________________

Signature of Employee