BREAK CERTIFICATE

Name & Address of :

Establishment

Name of Member :

Father/Husband’s Name :

PF Account No. :
Date of Appointment : Date of Leaving :

Statement of Period of Non Contributory Service

Year : No. of days for which wages/salary not earned
1995-1996 :
1996-1997 :
1997-1998 :
1998-1999 :
1999-2000 :
2000-2001 :
2001-2002 :
2002-2003 :
2003-2004 :
2004-2005 :
2005-2006 :
2006-2007 :
2007-2008 :
2008-2009 :
2009-2010 :
2010-2011 :
2011-2012 :
2012-2013 :
2013-2014 :

:
Total Break in service Days

Signature of Employer/Authorised Person

With Official Seal of Establishment

M/s. ARP Consulting & Solutions www.arpconsulting.in