SMS Integrated Facility Services Pvt. Ltd.

PERSONAL DETAILS

PHOTO
Date Of Joining :

Site Name :

Designation :

Employee Code :
Name of Employee :

Father’s Name :
Contact No. :
Email Id :
Present Address :

Native / Permanent Address :

DOB :
Blood Group :
Qualification :
Gender :
Religion :
Married/Unmarried :
Spouse Name & Age :
Nationality :
Languages Known :
Past Experience :

PF –UAN Number :
ESIC Number :
Esic Dispensary :

Uniform Size : Pant:- Shirt:- Shoes:-

New Appointment(Yes / No ): Replacement :
Documents Required : Aadhar / Pan Card/Education Certificate /Bank Passbook & Cheque.

Family details for Medical Claim Policy / ESIC :

Relationship with
Sr. No Name of Family Member DOB
Employee

1.

2.

3.

4.

5.

6.

Aadhar Card No :
PAN Card No :
Bank Details – Name of The Bank :
Savings Account No. : IFSC Code:

Employee Name : Signature:

SMS Operations Executive:

SMS Supervisor Signature: Date:
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 (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 :
 New Form : 11 - Declaration Form
(To be retained by the employer for future reference)

EMPLOYEES' PROVIDENT FUND ORGANISATION

Employees' Provident Fund Scheme, 1952 (Paragraph 34 & 57) and
Employees' Pension Scheme, 1995 (Paragraph 24)
(Declaration by a person taking up Employment in any Establishment on which EPF Scheme, 1952 and for EPS, 1995 is applicable)

1. Name of Member (Aadhar Name)

Father's Name Spouse's Name
2. (Please tick whichever applicable)

3. Date of Birth (dd/mm/yyyy)

4. Gender (Male / Female / Transgender)
5. Marital Status ? (Single/Married/Widow/Widower/Divorcee)

(a) eMail ID
6.
(b) Mobile No (Aadhar Registered)
Whether earlier member of the Employee's Provident Fund
7. Yes / No
Scheme, 1952 ?
Whether earlier member of the Employee's Pension
8. Yes / No
Scheme, 1995 ?
Previous Employment details ? (If Yes, 7 & 8 details above)
a) Universal Account Number (UAN)
b) Previous PF Account Number
9.
c) Date of Exit from previous Employment ? (dd/mm/yyyy)
d) Scheme Certificate No (If issued)
e) Pension Payment Order (PPO) (If issued)
a) International Worker Yes / No
b) If Yes, state country of origin (name of other country)
10.
c) Passport No.
d) Validity of passport (dd/mm/yyyy) to (dd/mm/yyyy)
KYC Details : (attach self attested copies of following KYC's) Must Enclose Scan copy for the following documents

a) Bank Account No. & IFS Code

11.
b) AADHAR Number
c) Permanent Account Number (PAN), If available

After Sep 2014 earned EPS

First EPF Member First Employment EPF Are you EPF Member If Yes, EPF Amount If Yes, EPS (Pension)
(Pension) Amount Withdrawn
Enrolled Date Wages before 01/09/2014 Withdrawn? Amount Withdrawn?
12. before Join current Employer?

Yes / No Yes / No Yes / No Yes / No

UNDERTAKING
1) Certified that the particulars are true to the best of my knowledge
2) I authorise EPFO to use my Aadhar for verification / authentication / eKYC purpose for service delivery
3) Kindly transfer the fund and service details, if applicable, from the previous PF account as declared above to the present PF 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
4) In case of changes in above details, the same will be intimated to employer at the earliest.

Date :
Place : Signature of Member

DECLARATION BY PRESENT EMPLOYER

A. The member Mr./Ms./Mrs. ……………..…………………….. Has joined on ……………………….and has een alloted PF Number ……….……..

B. In case the person was earlier not a member of EPF Scheme, 1952 and EPS, 1995: ((Post allotment of UAN) The UAN alloted or the member is)
Please Tick the Appropriate Option : The KYC details of the above member in the JAN 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 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 : Signate of Employer with Seal of Establishment