Permanent Account No.

: __________ (Mandatory)

FORM NO. 19
APPLICATION BY AN ADULT MEMBER OF THE EMPLOYEES PROVIDENT FUND SCHEME, 1952 FOR CLAIMING THE EMPLOYEES PROVIDENT FUND DUES The Employees Provident Fund Scheme, 1952 [Para 69(2)9b)] 1. Name of the member (in BLOCK letters) : Email ID : _____________________________________ Fathers name (or husbands name in the case of a married woman) : . Name & Address of the factory/establishment in which : Sapient Corporation Pvt. Ltd. the member was last employed Tower D & E, DLF Cyber Greens, DLF Phase III, Gurgaon Account No.: HR/GGN/26147/EPF/______ Sapient ID / Payroll ID :_____________ Date of leaving service : .. Reason of leaving service : . Full postal address (in BLOCK letters) : . ..

2. 3.

122002 4. 5. 6. 7.

8. Mode of remittance: Cheque drawn in your favour and send to the address as per item no. 7

Certified that the particulars are true to the best of my knowledge. Date of joining the establishment : . Date of Birth :

Signature of the member

The applicant has signed/thumb-impressed before me.

Signature of the employer or authorized official (Designation & Seal)

Signature or left/right hand thumb impression of the member

Date: Encl.: .. Declaration of non-employment I declare that I have not been employed in any factory/establishment to which the Act applies for a continuous period of not less than 2 months immediately preceding the date of my application for final withdrawal of my provident fund money. Date: . Signature or left/right hand thumb impression of the member Advanced Stamped receipt Received a sum of Rs. * .. (Rupees * only) from Sapient Corporation Employees Provident Fund Trust by cheque drawn in my favour towards the Full & Final settlement of my Provident Fund Account.

Affix Re. 1 Revenue Stamp

Signature or left/right hand thumb impression of the member