The Employees' Provident Fund Scheme, 1952

Form - 5

Paragarph 36 (2) (a) and (b)

Employees' Pension Scheme, 1995

Paragarph 20 (4)
Return of Employees' qualifying for membership of the Employees' Provident Fund, Employees' Pension Scheme & Employees' Deposit Linked Insurance Fund for the first
time during the month of
To be sent to the Commissioner with Form 2
Name & Address of the Factory/ Establishment :
Code No. of Factory/ Establishment :

S. No Account No.

Name of the Member

(in BLOCK letters)

Father's Name or Husband's

Name in case of married women

Age/ Date of
Birth

Total Period of
Previous Service
Date of
(excluding period
Sex Eligibility for
of breaks) as on
Service
the date of joining
the Fund

Remarks

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15

Signature of the employer or other authorised officer and stamp of the Factory / Establishment
Note: Please furnish details of the membership in remarks column if the employee was a member of Employees' Provident Fund and Employees' Family Pension scheme
before joining yourself/ factory. i.e. Account No. and/ or the name and particulars of the last employer.