secur

Bytamorph Zona Pvt Ltd

PERSONAL DETAILS
Name:
shan
Father/Spouse Name:
foitm Kumas
Present Address:B/oo |2s GURU Namalo

Permanent Address:

Lay
Date of Birth: o- o7-)44 6 Marital Status:

Mobile No:
+38 1yM658 EmailID:
Aadhaar No: Gender:
Name as per Aadhaar:
Bhan
Pan Card No: Blood Group: Bt
PF UAN No:o132 4S4 )o2o ESIC No:

Bank Details Bank Name: Hpf Bormh

Bank A/c No: 5o) co 38 )4957)o IFSC Code: H DfC0ooyt64
Branch Name : Vihas Ma Shahorhua/eType : SaVimg
Emergency Contact Details
a873325S8
Name: tm Kume Relation: fath Contact No: 83332 SS

EDUCATIONALDETAILS
University/ Percentage/ Specialization
Degree From
Grade
Institute

BA) Hons
2 tn 2o13 A

668/A, 9th Cross, Vijayanagar 1* Stage, Mysore 570017

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 Secur Bytamorph Zona Pvt Ltd

EMPLOYMENT DETAILS (LAST THREE ORGANISATIONS)

Period of Service
S.No Organization Annual CTC
Designation From To

1
td 2o2| 7o22 32PA
2

FAMILY DETAILS
S.No Name Relation Occupation Date of Birth

1 tom ime hovt Tob 2z)oy }1467

2
AsHA matt Heuss ahe
3
hmond kemo Bocthe hovt Tob t6o8|1444
4

PROFESSIONAL REFERENCES
Name: Name:

Organization: S Bytameh ongyorganization:

ad
Designation:

Contact No:
Unstoney Su ccay toDesignation:
q4s to 6549 Contact No:
Tesdng

668/A, 9th Cross,Vijayanagar 1 Stage, Mysore 570017

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 secur Bytamorph Zona Pvt Ltd

DECLARATION
Ihereby declare that the above statements made in my application form are true,
complete and correct to the best of mny
knowledge and belief. In the event of any information being found false or incorrect at any stage, my services are liable to be

terminated without notice.

Date:
o6-02- 2025
Place: Nela Signature

668/A, 9th Cross, Vijayanagar 1 Stage, Mysore 570017

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 Form No. 11 (New)
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 APERSON TAKING UP EMPLOYMENT IN AN ESTABLISHMENT ON WHICH EMPLOYEES' PROVIDENT FUND SCHEME.
1952 AND/OR EMPLOYEES' PENSION SCHEME, 1995 ISAPPLIÇABLE.
(PLEASE GO THROUGH THE INSTRUCTIONS)

1) NAME (JmE)
MR. Ms. MRS.
(PLEASE TICK)

2) DATE OFBIRTH D D M M Y Y Y Y

3) FATHER'S/ MR.
HuSBAND's NAME
Kul mAR

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

(PLEASE TIcK)

5) GENDER MALE FEMALE TRANSGENDER

(PLEASE TIcx)

6) MOBILE NUMBER
(IF ANY) 38 6 8
7) EMAIL ID (IF ANY)
a S
( m
8) WHETHER EARLIER AMEMBER OF THE EMPLOYEES' PROVIDENT FUND SCHEME, 1952?
(PLEASE TICK) YES NO

9) WHETHER EARLIER AMEMBER 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 EMPLOoYMENT DETAILS
AT (10,11&12):
Page 1 of 3
 A. PREVIOUS EMPLoYMENT DETAILS
10) THE DETAILS OF THE UNIVERSAL ACCOUNT
NUMBER (UAN) OR PREVIOUS PF MEMBER ID:
UAN
OR 32 o2o
PREVIOUs PF MEMBER ID
REGION CoDE OFFICE CoDE ESTABLISHMENT ID ExTENSION AccoUNT NUMBER

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

MEMBER ID (DD/MM/Y) Y

6
2
12) (A) IF SCHEME CERTIFICATE ISSUED FOR
(B) IF PENSION PAYMENT ORDER (PPO) PREVIOUS EMPLOYMENT, THEN SCHEME CERTIFICATE NUMBER:
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

14) EDUCATIONAL NON SENIOR POST

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

15) MARITAL STATUS MARRIED UNMARRIED WIDOW/ WIDOWER DIVORCEE

(PLEASE TICK)

16)SPECIALLY ABLED YES No IFYES, TICK THE CATEGORY

(PLEASE TICK) LOcOMOTIVE VISUAL HEARING

Page 2 of 3
 NUMBER REMARKS, IF ANY
17) KYC DETAILS KYC DOCUMENT TYE NAME AS ON KYC DOCUMENT
BANK ACCOUNT-1* 5o l003i44 S? lo
NPR/AADHAAR
Bhan 6 483 g os4 5/4)
Bham
PERMANENT ACCOUNT
NUMBER (PAN)
PASSPORT Bhanu
Bhamy X4456SS
DRIVING LICENCE

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 WITHTHIS 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 AMEMBER OF EPF SCHEME, 1952 AND/OR EPS, 1995,
(1) I HAVE ENSURED THE CORRECTNESs OF MY UAN/ PREVIOUS PF MEMBER ID.
(u)THIS MAY ALSO BE TREATED AS MY REQUEST FOR TRANSFER OF FUNDS AND SERVICE DETATLS 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)) IAM AWARE THAT I CAN SUBMIT MY NOMINATION FORM THROUGH UAN BASED MEMBER PORTAL.

DATE:
c6-02- 2o2 S
PLACE: Naida 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 AMEMBER 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 AMEMBER 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 DSCOF 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 OFEsTABLISHMENT

Page 3 of 3
 (FORM 2REVISED)

NOMINATION AND DECLARATION FORM FOR UNEXEMPTED/EXEMPTED ESTABLISHMENTS

Doclaraton and Nomination fom under the Fmployccs Provident Funds and Employces Pension Schemes
Paragraph and61(0)ofhe Lmployces Providont Fund Scheme I932 and Paragraph I8 of the Employces
Pension Scheme l995)

L Name (IN BLOCKLETTERS) BHANU

Name Father's /Husband's Name
uumAR
Surmame

2Date of Buth ollo ?}/a46 3 Account No So joo3 |44S4 )o

4Sex MAE HMALE: 5. Marital Status

6. Address Permancnt Temporary : luca Lasm

Nage
PART - A (EPF)
Ihereby nominate the person(s) cancel the nomination made by me previously and nominate the person(s) mentioned below
to roccive the amount standing to my credit in the Employces Provident Fund, in the event of my dcath.
If the nomincc is minor
Name of the Address Nomincc's Date of Total amount or share of name and address of the
Nominee (s) relationship with Birth accumulations in guard1an who may receive
the member Provident Funds to be the amount during the
paid to each nominee minority of the nomine

3 4 6

ASHA Bjoo) 2s
pusa
liamkmBl ) 2S fathe

"Certified that Ihave 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 depcndent upon me.

Strike out whichever is not applicable

Bhans
Signature/or-thumb impression
of the subscriber

PART - (EPS)
Para 18
Ihereby furnish below particulars of the members of my family who would be cligible to reccive 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
(0) (2) (3) (4)
AShA Bloe) 2Shnaa
Certified that |have no family as defined in para 2 (vii) of the
family hcreafier I shall furnish Particulars there on in thc above Employees's Family Pension Scheme 1995 and should I acquire a
form.

Ihereby nominate the following person for

receiving the monthly widow pension (admissible under para 16 2 (a) )
event of my death without leaving any cligible family member for receiving pension. & (ii) in the

Name and Address of Date of Birth

the noninee Relationship with member

AsHA B/oe)25 huRU

MathY
lax Naqo s

Date 6o2-202S

Signature or thumb impression

of the subscriber

CERTIFICATE BY EMPLOYER
Certificd that the above declaration and nomination has been signed / thumb impressed before me by Shri Smt.
Miss
cmploycd in my cstablishment afier 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,
address)
(Give here name or description of the establishment with full

1. Shri/Shrimati B.AAN.
hereby nominate the
(Name in full here) whose particulars are given in the statement below,
death as also the
person(s) mentioned below to receive the gratuity payable after my become
gratuity standing to my credit in the event of my death before that amount has
direct that the said amount of
payable, or having become payable has not been paid and
nominee(s).
gratuity shall be paid in proportion indicated against the name(s) of the
family within
2. Ihereby certify that the person(s) nominated is/are a member(s) of my
1972.
the meaning of clause (h) of Section 2 of the Payment of Gratuity Act,
(h) of Section 2 of
3. Ihereby declare that Ihave no family within the meaning of clause
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.
.to the
5. Ihave excluded my husband from my family by a notice dated the
the said Act.
controlling authority in terms of the proviso to clause (h) of Section 2 of
6 Nomination made herein invalidates my previous nomination.
Nominee(s)
Proportion by
Name in full with full Relationship with Age of which the
address of nominee(s) the employee nominee gratuity willbe
shared

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

1. shazB loe)2s 4uxR

2. Nanato lvsa
3.

4.
So on
 Statement

2
Name of employee in full

Sex
Rhan
Mal
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 o)o?) 2o22
Permanent address:

Village Thana Sub-division

Post Office : Lugmu eaoy District :at J State

Place: h
Date: o(6 - O2 -2o2S Bl
Signature/Thumb-impression of the Employee
Declaration by Witnesses
Nomination signed/thumb-impressed before me
Name in full and full address of witnesses
Signatureof Witnesses
shra, B-3 wo j'da,
1. Vi ku 8echs (2
1.

2
2.Paya hauma,se2,ANo-313
Place: Rajauep Afsetment
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 copyof nomination in Form 'F' filed by me and duly certified by the
employer.
Bls
Date: o6 -o2-2o 2 S Signature of the Employee

Note-Strike out the words/paragraphs not applicable.

 FORM I
(See Rule 3]
Nomination and Declaration Form

1. Name of person making nomination: BH ANU

(In Block letters)
2. Father's/Husband's Name: PRITAM ku m A R
3. Date of Birth:

4. Sex:

5. Marital Status:
6. Address:

Permanent:
Temporary:

Ihereby nominated the person(s)/cancel the nomination made by me previously and

nominated the person(s) mentioned below to receive any amount due to me from the
employer, in the event to my death:

Name of Address Nominee's Date of Total amount If the nominee is

nominee/ relationship birth of share of minor, name
nominees with the accumulations relationship and
member in credit to be address of the
paid to each guardian who
nominee may receive the
amount during
the minority of
nominee

(1) (2) (3) (4) (5) (6)

AsHA B-lol2s

42.
1. Certified that Ihave no family and should Iacquire a family hereafter, the above
nomination shall be deemed as cancelled.
2. *Certified that my father/ mother is/ are dependent upon me.
3. *Strike out whichever is not applicable.

Blo
Signature or the thumb
Impression of the employed person.

CERTITICATE BY EMPLOYER

Certified that the above declaration and nomination has been signed/thumb impression before
me by Shri./ Smt./ Kum. employed in myestablishment after he/ she has read
the entry/ entries have been read over to him/ her by me and got confirmed by him/her.

Place: Signature of the employer or other

Date: authorised officer of the establishment
And designation

Name and address of the factory/

Establishment and rubber stamp thereof.