Employee Code No.

HR Assesment Sheet

PT5391
Name in Block
Letters AKASH THAKUR

Date of Joining 12/10/2019

Department IT

Designation SYSTEM ENGINEER

Location CHANDIGARH
:
_________________________________________________
Branch Coordinator ____
:
_________________________________________________
Attendance ____
:
_________________________________________________
ID Card ____
:
_________________________________________________
Signature of HR ____
:
_________________________________________________
Checked by ____
:
_________________________________________________
Remarks ____
 Documents Checklist for Personal Files

Name: ____________________________________________________
Sr. No. Documents Qty Remarks

Source of
1 Documents Photographs 5
2 Resume 1
3 Test Papers and results (If any) 1
4 Interview Rating Form 1
5 Employment advise Form 1
6 PRL letter & Accpetance 1
Company Details

7 Joining Form 1
8 Personal Info Form 1
9 Appointment Letter 1
10 PF Form 1
11 Gratuity Form 1
12 Investment Declereation Form 1
13 Verification Copy 1
14 KRA Form 1
15 10th Mark sheet 1
16 12th Marks Sheet 1
17 Diploma 1
Educational

18 Degree Marks Sheet 1

19 Degree certificate/provisional degree certificate 1
20 PG Marks Sheet (if any) 1
21 PG Certificate (if any) 1
22 Certification (if any) 1
23 Any other Degree / Certificate 1
24 Appointment Letter for previous company 1
Last Working

25 Last Salary slip 1

26 Relieving letter from all previous employers 1
27 Experience Letter 1
28 Full n Final Settelement Letter 1
29 Voter ID 1
ID Proof

30 Passport Copy 1
 ID Proof
31 Aadhar Copy
Address Proof (Driving Licence or any other 2
32 documents) 1
33 Code of Conduct 1
Other Documements
34 NDA 1
35 1
(If Any)
36 1
37 1
38 1
39 1
 ISO 9001: 2015 Doc. No. PG/QSP/PG/HR/020
Joining Forms Rev. No / Date. 01 / 14-10-2019
Ref. No. PG/HR/020

Please Paste your recent color

Photograph

Employee Personal Information
Title AKASH THAKUR
: Mr.
Name as per Aadhar
: ____________________________________________________
Date of Birth as per Aadhar
: 10/19/1992
Father Name MANWAR SINGH
: Mr.
Gender
: ____________________________________________________
Martial Status
: SINGLE
Blood Group
: B+
Email ID
: akash18.thakur@gmail.com
Contact Number
: 8837123263
Alternate Contact Number
: ____________________________________________________
Emergency Contact Number
: 9988770138
Language Known PUNJABI ENGLISH
: HINDI
Date of Marriage
: N/A
Physically challenged
: NO
Present Address Detail
Present Address
: HOUSE NO. 3645 SECTOR-46C
State
: CHANDIGARH
District
: ____________________________________________________
Taluk
: ____________________________________________________
Pin Code
: 160047

Permanent Address Detail
Permanent Address
: ____________________________________________________
State
: ____________________________________________________
District
: ____________________________________________________
Taluk
: ____________________________________________________
Pin Code
: ____________________________________________________
Proof
Proof of Record Year of Year of Attachment
Issue Validity
Number

PAN ANOPT7967L

Aadhar 6935-7227-8805
Driving License
Passport
Vote ID

Statutory Details
Previous UAN:
: ____________________________________________________
Previous PF Number (If any)
: ____________________________________________________
Previous ESI Number
: ____________________________________________________

Family Details
Family Member Name Date of Aadhar Proof Can be
Birth of Dependent nominee for
ESI / PF /
Gratuity
Relationship (Yes/No)
MEENA THAKUR MOTHER Yes
SAGAR THAKUR BROTHER No
No
No

Education Detail
Basic
Marks
Education N
Obtained (In Passing Grade Attachment
%)a Year
m
e

o
f
 Technical
Marks
Education N
Obtained (In Passing Grade Attachment
%)a Year
m
e

o
f

B
o
a
r
d
/
Professional
Education N
Marks Passing Grade Attachment
U
a
Obtained Year
n
m
i
e
v
e
o
r
f
s
Certification Details i
B
t
Certification Type o T Date From Date To Attachment
y of the
Name
a o
Institute
r p
d i
/ c

Training Details U N
a
n Basic
Training Type i T m Date From Date To Attachment
Name
v eoof the
Institute
e p
r i
s c
i
Technical
t N
Training Type y aT Date From Date To Attachment
om
Namee of the
p
Institute
i
c

Professional
N
Training Type T
a Date From Date To Attachment
Name of the
om
Institute
pe
i
Service History
Name of the Organization Date of Salary Attachment
Designation Relieving Drawn

Bank Details

Bank Name : INDIAN OVERSEAS BANK

Account Number
: 18100 10000 10927
IFSC
: _______________IOBA0001810
 (G.P.V.) --- Y-1531-20,000-1-2006

DECLARATION FORM
Form 1
To be filled in only if the employee after reading instruction overlief. Two Postcard size photographs are to be
attached with this form. This form is free of cost.

(A) INSURED PERSON'S PARTICULARS (B) EMPLOYER'S PARTICULARS

1. Insurance No. Employer's Code No.
2. Name
Date of
(In Block ______________________________________ #REF!
Appointment
capital)
3. Father's / Name & Address of the employer
Husband's
Mr.
Name
DDMMYYYY Maritail Status Sex
Date of Birth
10/19/1992 SINGLE _________
12.In case of any pervious employment
please fill up the details as under :-
Present Address Permanent Address
_________________________
_______________ ___________________________________________
a) Pervious ins. No.
____________
HOUSE NO. 3645 SECTOR- _________________________
____________ _______________
_______________
46C __
_______________ b) Emplrs. Code No.
____________ _______________
State CHANDIGARH c) Name & Address of the employer with
____________ State _______
_______________
Telephone No & E-mail Address
Taluk ____ Taluk _______
____________________________________________________
District ____________________________________________________
District
Pin Code 160047
____________________________________________________
Pin Code

Branch Office Dispensary

Details of the Nominee u/s 71 of ESI Act 1948/ Rule 56(2) of ESI (Central Rules, 1950 for paymemt of cash
benefit in the event of death.
Name Relationship Nominee Address
MEENA THAKUR MOTHER Yes
SAGAR THAKUR BROTHER No
0 0 No
0 0 No
__________________________________________
__________
I Hereby declare that the particulars given by me are correct to the best of my knowledge and belief, I
undertake to intimate the corporation any changes in the membership of my family within 15 days of such
change.

Counter Signature by the employer

______________________________________
r
Signature with seal Signature/ T.I of IP

FAMILY PARTICULARS OF INSURED PERSON

Date of
Birth/ age
Relationsh Whether residing If 'NO' state place of
as on with him/her? Residence
Sr No. Name ip with the
date of
Employee Yes No Town State
form filling
1 MEENA THAKUR 0 MOTHER
2 SAGAR THAKUR 0 BROTHER
3 0 0 0
4 0 0 0
5 0 0 0
 6 0 0 0
7 0 0 0

-----------------------------------------------------------------------------------------------------------------------------------------------------

Name ______________________________________
Date of
1. Insurance No. Appointme #REF!
nt (Space for Photograph)

Branch Office Dispensary

Employeer's code No.& Address

Validity

Date r -----------------------------------
Signature/ T.I of IP Signature of B.M. with seal
 INSTRUCTIONS

1 Submition of Form-I is governed by regulation 11 & 12 of ESI (General ) Regulati

2 "Family means all of any of the following relatives of an Insured Person Namely:-

(i)a Spouse (ii) a minor legitimate or adopted child dependant upon the I.P.; (iii) a
child who is wholly dependence on the earning of the I.P. and who is (a) receiving
education, till he or she attains the age of 21 years (b) an unmarried daughter; (iv)

3 Identity card is Non- transferable.

4 Loss of Identity card be reported to the employer / Branch Manager immediately.

5 Submission of false infoemation attacts pencil action under section of 84 of ESI Act, 1984.

6 This form duly filled in must reach the concerned Branch Office eithin 10 days of appointment of an Employee

As an Insured person you and your dependent family members are entitled to full
medical care. The other benefit in cash include (1) Sickness benefit (2) Temporary
7
disablement benefit (3) Permanent disablement benefit (4) Dependence Benefit
and (5) Materni

8 For more details visit website of ESIC at www.esic.org. in or contact Regional office or Branch Office.

For Branch Office Use Only

1. Date of allotment of Ins. No

1. Date of allotment of Ins. No

1. Date of allotment of Ins. No

1. Date of allotment of Ins. No

Date of Birth/ Relationship Whether residing with If 'NO' state place of

Sr him/her? Residence
Name age as on date with the
No.
of form filling Employee
Yes No Town State

1 MEENA THAKUR 0 MOTHER #VALUE!

2 SAGAR THAKUR 0 BROTHER #VALUE!

3 0 0 0 #VALUE!

4 0 0 0 #VALUE!

5 0 0 0 #VALUE!

7
8
 Form-2 (Revised)
Date of Joining 6/1/2009
NOMINATION AND DECLARATION FORM

FOR UNEXEMPTED/EXEMPTED ESTABLISHMENT

Declaration and Nomination for under the Employee's Provident Funds and
Employee's Pension Schemes

(Paragraph 33 and 61 (1) of the Employee's Provident Fund Scheme 1952 & Paragraph 13 of the
Employee's Pension Scheme, 1955)

1. Name (In 6. Account No.

block letters) ________________________________
2. Father's /
Husband's Name _______________________________________
Permanent Address
Mr. _______________________________________
_______________________________________
_______________________________________
3. Date of Birth 10/19/1992
_______________________________________
_______________________________________
4. Sex Temporary
HOUSE NO.Address
3645 SECTOR-
________________________________ __________________________
46CCHANDIGARH________________________
_______________________________________
5. Marital Status SINGLE _______________________________________
PART - A (E.P.F.)
__160047

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 Employee's Provident Fund, in the
event of my death.
Name of the Address Nominee's age of Total amount of share If the nominee is a
Nominee / relationship with nomi- of accumulations in minor, name and
Nominees the member nee(s) Provident Fund to be address of the
paid to each nominee guardian who may
receive the amount
during the minority of
the nominee
1 2 3 4 5 6

MEENA THAKUR MOTHER Yes

SAGAR THAKUR BROTHER No
0 0 No
0 0 No
0 0 0

1. * Certified that I have no family as defined in para 2(g) of the Employee's Provident Fund scheme, 1952 and
should I acquire a family hereafter the above nomination should be deemed as canelled.

2. * Certified that my father/mother is/are depeneded upon me.

* Strike out whichever is not applicable

r
Signature/or thump impression of the subscriber
 PART - B (E.P.S.)
(PARA - 18)

I hereby furnished below particulars of the members of my family who would be eligible to receive
widow / children pension in the event of my premature death.

Serial No. Name of the family member Address Age Relationship with the member
1 2 3 4 5
1
2 Not Applicable
3

** Certified that I have no family as defined in para 2(b) of the Employee's Pension Scheme, 1995 and should I
acquire a family hereafter I shall furnish particulars thereon 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 the death without leaving any eligible family member for receiving pension.

Name & Address of the Nominee Date of Birth Relationship with member
MEENA THAKUR 12/30/1899 MOTHER
SAGAR THAKUR 12/30/1899 BROTHER
0 12/30/1899 0
0 12/30/1899 0
0 12/30/1899 0

Date : 6/1/2009
r
Signature of thump impression
of the Subscriber

* Strike out whichever is not applicable

CERTIFICATE BY EMPLOYER

Certified that the above declaration and nomination has been signed/thump impressed before me by
Shri/Smt.Kum. XYZ employed in my
establishment after he/she has the entries/the entries have been read over to him/her by me and got
confirmed by him/her.

Place: xxxxx

CBA

Date : 6/1/2009
Name & Address of the Factory / Establishment Signature of the Employer or other
and Rubber Stamp thereof authorised officer of the establishment
 EMPLOYEES PROVIDENT FUND
New Form No.11- Declaration
ORGANIZATION Form
(To be retained by the employer for future
Employees provident funds scheme, 1952 reference)
(paragraph 34 & 57) & Employees pension
scheme 1995 (paragraph 24)

Emp Code:

Company:
(Declaration by a person taking up employment in any establishment on which EPF Scheme, 1952 end /of
1 EPS1995 is applicable)
Name of the member
AKASH THAKUR
2 Father’s Name ( ) Spouse’s Name ( )
(Please Tick Whichever Is Applicable) Mr.

3 Date of Birth (DD/MM/YYYY) 19 10 1992

______________________________________
4 Gender: ( male / Female /Transgender ) ______________
5 Marital Status (married /Unmarried /widow/divorce) SINGLE
6 (a)Email ID:
(b)Mobile No: 8837712326

7* Whether earlier a member of Employees ‘provident Fund Scheme 1952 Yes  No

8* Whether earlier a member of Employees ‘Pension Scheme ,1995  
Yes No

If response to any or both of (7) & (8) above is yes. MANDATORY FILL UP THE
______________________________________
a) Universal(COLUMN 9)
Account Number(UAN) ______________
b) Previous PF a/c AP HYD EST.CODE EXTN PF NO.
9 No
c) Date of exit from previous employment
(DD/MM/YYY)
d) Scheme Certificate No (if Issued )
e) Pension Payment Order (PPO)No (if Issued)
a) International Worker: Yes  No
b) If Yes , State Country Of Origin (India /Name of Other 
10
Country)
c) Passport No
d) Validity Of Passport (DD/MM/YYY)
to(DD/MM/YYY) INDIAN
KYC Details: OVERSEAS
(attach Self attested copies of following
KYCs) ** BANK,18100,__________________________
a) Bank Account No .& IFS code
__________________________
11
b) AADHAR Number (12 Digit)
6935-7227-8805
c) Permanent Account Number (PAN),If available
ANOPT7967L
 UNDERTAKING
1) Certified that the Particulars are true to the best of my Knowledge
2) I authorize EPFO to use my Aadhar for verification / e KYC purpose for service delivery
3) Kindly transfer the funds and service details, if applicable if applicable, from the previous PF 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
4) In case of changes In above details the same Will be intimate 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 been allotted PF Number……………………………….
B) In case 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 PF account number /UAN 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 (Form13) for
transfer
of funds from his previous establishment.
Date Signature of Employer
With seal of Establishment
Declaration
yer for future

1952 end /of

ared above to the
oyer has been

ember

……………….

us member ID as

tificate and transfer

claim (Form13) for

nature of Employer
 Form `F'
(See Sub-rule (1) of Rule 6)
NOMINATION

To:

1. Shri/Shrimati/Kumar____________________________________________________

Whose particulars are given in the statement below, hereby nominate the persons'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 herby certify that the person(s) mentioned is a/are member (s) of my family within the meaning of
clause (h) of section 2 of the Payment of Gratuity Act, 1972.

3. I hereby certify 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 dependnet 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 provision to clause (h) of section 2 of the said Act.

6. Nomination made herein invalidates my previous nominee(s)

Nominees

No. Name in full with address Relationship with Age of Proportion by which the
of nomine (s) the employee nominee gratuity will be shared
1 MEENA THAKUR MOTHER Yes

2 SAGAR THAKUR BROTHER No

3 0% 0% No

4 0% 0% No

5 0% 0% 0%

6 0% 0% 0%
 STATEMENT

1. Name of employee in full: 0

2. Sex : 0

3. Religion :

4. Whether unmarried/ married/ widow / widower 0

5. Department/ Branch/ Section/ where employed

6. Post held with Ticket or Serial No. if any

7. Date of address
_______________________________________________________________
8. Permanent address _______________________________________________________________
________

Village Thana Sub-Division

Post office District 0 State #VALUE!

Place

Date r
Signature/Thump impression of the employee

DECLARATION BY THE WITNESSES

Nomination Signed/thumb impressed before me

Name in full and full address of witnesses Signature of witnesses

Place

Date
CERTIFICATE BY THE EMPLOYER

Certified that the particulars of the above nomination have been verified & recorded in this establishment.

Registration No. GR.

Date
Employer's Signature & Designation

Name & Address of Establishment or Rubber Stamp

ACKNOWLEDGEMENT BY EMPLOYER

Received the duplicate copy of nomination in form `F' filed by me and duly certified by the employer.
r