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)
MR . MS. MRS.
(PLEASE TICK)

2) DATE OF BIRTH D D M M Y Y Y Y

3) FATHER’S/ MR .
HUSBAND’S NAME

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

(PLEASE TICK)

5) GENDER MALE FEMALE TRANSGENDER

(PLEASE TICK)

6) MOBILE NUMBER
(IF ANY)

7) EMAIL ID (IF ANY)

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 ILLITERATE

NON-
MATRIC
SENIOR
GRADUATE
POST
DOCTOR
TECHNICAL/
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

Page 2 of 3
17) KYC DETAILS KYC DOCUMENT TYPE NAME AS ON KYC DOCUMENT NUMBER REMARKS, IF ANY
BANK ACCOUNT-1* IFSC CODE*
NPR/AADHAAR
PERMANENT ACCOUNT
NUMBER (PAN)
PASSPORT EXPIRY DATE
DRIVING LICENCE EXPIRY DATE
ELECTION CARD
RATION CARD
ESIC CARD
* Mandatory Field (NOTE: BANK ACCOUNT NUMBER (ALONG WITH IFSC CODE) IS MANDATORY. YOU
ARE HOWEVER ADVISED TO PROVIDE ALL KYC DOCUMENTS AVAILABLE WITH YOU IN ADDITION TO MANDATORY KYCS TO
AVAIL BETTER SERVICES. SELF-ATTESTED PHOTOCOPIES OF THE DOCUMENTS MUST BE ATTACHED WITH THIS FORM.

C. UNDERTAKING:
A. I CERTIFY THAT ALL THE INFORMATION GIVEN ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE AND BELIEF.
B. IN CASE, EARLIER A MEMBER OF EPF SCHEME, 1952 AND/OR EPS, 1995,
(I) I HAVE ENSURED THE CORRECTNESS OF MY UAN/ PREVIOUS PF MEMBER ID.
(II) THIS MAY ALSO BE TREATED AS MY REQUEST FOR TRANSFER OF FUNDS AND SERVICE DETAILS IF APPLICABLE FROM
THE PREVIOUS 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 USING HIS DIGITAL SIGNATURE CERTIFICATE).
(III) I AM AWARE THAT I CAN SUBMIT MY NOMINATION FORM THROUGH UAN BASED MEMBER PORTAL.

DATE:
PLACE: SIGNATURE OF MEMBER
DECLARATION BY PRESENT EMPLOYER
A. THE MEMBER Mr./Ms./Mrs. ………………………….. HAS JOINED ON ………………….. AND HAS BEEN ALLOTTED PF MEMBER ID
…………………………………………...
B. IN CASE THE PERSON WAS EARLIER NOT A MEMBER OF EPF SCHEME, 1952 AND EPS, 1995:
 (POST ALLOTMENT OF UAN) THE UAN ALLOTTED FOR THE MEMBER IS …………………………
 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. IN CASE THE PERSON WAS EARLIER A MEMBER OF EPF SCHEME, 1952 AND EPS, 1995:
 THE ABOVE MEMBER ID OF THE MEMBER AS MENTIONED IN (A) ABOVE HAS BEEN TAGGED WITH HIS/HER UAN/PREVIOUS
MEMBER ID AS DECLARED BY MEMBER.
 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.
□ AS THE DSC OF ESTABLISHMENT ARE NOT REGISTERED WITH EPFO, THE MEMBER HAS BEEN INFORMED TO FILE
PHYSICAL CLAIM (FORM-13) FOR TRANSFER OF FUNDS FROM HIS PREVIOUS ESTABLISHMENT.

DATE: SIGNATURE OF EMPLOYER WITH SEAL OF ESTABLISHMENT

Page 3 of 3
 (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 :
 Payment of Gratuity (Central) Rules
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 Age of Proportion by which

address of nominee(s) the 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.

 Non-Disclosure Agreement

As an employee of Apollo Pharmacies Limited (APL) or of a direct or indirect subsidiary / parent of

APL* (a “Subsidiary”), I,Mr/Ms.___________,am entering into this agreement with APL*
and each of its subsidiary / parent(s).
In consideration of my continuing employment with APL*, I agree as follows:
1. Definitions:
a. APL*: As used in this agreement, the word “APL” followed by an asterisk (*) refer
collectively to Apollo Pharmacies Limited and its subsidiary / parent(s).
b. Confidential Information: means any information about APL* or about any past or present
client of APL* which is produced or acquired by me as a result of my employment with
APL* unless such information is generally available to the members of the public.
2. General Obligation to APL
a. Conflicts of interest: While employed by APL*, I will not do anything which interferes with
the performance of my work for APL* or which conflict with the interest of APL*.
b. Non-discrimination: While employed by APL*, I will use my best efforts to further the policy
of professional advancement with APL*, shall not be affected by race, color, religion,
nationality, ethnic background, age, sex, sexual preferences or any other factor unrelated to
professional capacity and performance.
c. Work Product: Everything I produce alone or jointly with others, in the course of work for
APL* shall be the property of APL*. Unless otherwise specifically agreed by APL* in writing, I
will not have or claim any personal right to anything produced by me or others in the course of
work for APL*.
d. Publishing of materials: Unless required for the performance of my work for APL*, or
otherwise approved by APL*, I will not publish or distribute to anyone outside APL* any
information or material attributed to APL* or in which I am identified as an employee of APL*.
3. Confidential Information
a. Non-Disclosure: I will not identify or disclose any client of APL* to anyone outside APL*
without the permission of that client and Management of APL*.
b. Restriction: During and after my employment by APL*, unless otherwise specifically
approved by APL &, I will not:
i. Unless required for performance of my work for APL*, copy or reproduce
anything which contains Confidential Information; or
ii. Disclose Confidential Information; or
iii. Use Confidential Information for the benefit of anyone other than APL* or a
client of APL* to whom the Confidential Information relates
c. Return of Information: I will turn over to APL* everything that contains any Confidential
Information whenever requested by APL*, or by a client of APL* to whom the Confidential
Information relates, and in any case no later than 15 days after I have ceased to be employed
by APL*.
4. Restriction on future employment:

Page 1 of 2
 a. Advising competitors of APL*: For 18 consecutive months after ceasing to be employed by
APL*, I will not assist anyone engaged with any APL* competitor unless such assistance
consist of services or concerns a subject different from the work which I did or reviewed for
the project. Subject to this restriction and other provisions of this agreement, I will be free to
work.
b. Restart Provision: If I violate the provision of section 4.(a), intentionally or otherwise, and a
legal notice is served by APL* in writing thereof, the period of restriction shall begin again
from the time of the violation, or completion of arbitration process or legal proceedings,
whichever is later, and shall continue until completed without violation for the full period (18
months) provided.
5. Other Provisions:
a. Obligation to APL* subsidiaries: My obligation under this agreement shall extend to
APL* and each of its subsidiaries / Parent; and APL* and any subsidiaries / Parent have the
right to enforce this agreement directly or with any Subsidiary.
b. Amendment of Waiver: No provision of this agreement shall be amended or waived unless
approved in writing, signed by theHead–HR of APL*. Waiver of any provision on one
occasion shall not apply to any other occasion, unless explicitly specified otherwise.
c. Governing Law: This agreement reflects the policy of APL* and its Representative of
APL*. This agreement shall be governed, interpreted and enforced in accordance with the
laws of India.
d. Forum: Until such time, if any, I am selected as Representative of APL*, any suit, action or
other legal proceeding based upon or relating to the interpretation or effect of 3(b) above
shall be commenced or maintained in any local court having the jurisdiction to apply any
local law applicable to me. Otherwise, any suit, action or other legal proceedings based upon
or relating to any provision of this agreement shall be commenced and maintained in a court
which has its principal officers in Hyderabad, Telangana, India. I agree to accept the
jurisdiction of such a court.
e. Severability: The various provisions of this agreement are severable; and the invalidity or
un-forcibility of any provision in this agreement shall not affect the validity or enforceability
of any other provision in this agreement.

In witness whereof, and intending to be legally bound, I have signed, sealed and delivered this
agreement at Hyderabad on________________, in the presence of at least one of those signing below.

_______________________________________
(Name and Signature of the employee)

_______________________________________
(Name and Signature of the Witness)Accepted for Apollo Pharmacies Limited

_______________________________________
Signature
APL*

Page 2 of 2
 Date:……………………………

Place:………………………….

To,

The HR Department,
Apollo Pharmacies Limited,
………………………………………………….,
…………………………………………………,
………………………………………………..,

Sir,

Subject: Self Declaration of Criminal/Negligence back Ground-Reg

/ /
I……………………………………………………………………………S/O D/O W/O…………………………………………………………………

Residing at H.No……………………………………………………..street……………………………………………………………………………..

Locality…………………………………………………………………….post…………………………city/Town…………………………………...

Hereby declare that, I have no criminal /negligence background/history in the past in any jurisdiction of
police station and any previous service record is free from blemish.

I shall declare that, I have never been involved /convicted in any civil/criminal proceeding s under the law in
any court of India.

Further I will produce verification certificate issued by police department as soon as Possible.

Yours Sincerely

……………………………………….

a) Signature with date:……………………………………………

b) Employeename:………………………………………………….

c) Emp No:……………………………………………………………..

d) Designation:……………………………………………………….

e) Department:………………………………………………………

f) Mobile No:………………………………………………………….
 APOLLO PHARMACIES LIMITED - ID CARD

1 EMPLOYEE NAME

2 EMP NUMBER

3 DESIGNATION

4 EMERGENCY CONTACT NUMBER

5 DEPARTMENT

6 BLOOD GROUP

7 DOJ

8 ADDRESS