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Form 11

 THE EMPLOYEES’ PROVIDENT FUNDS SCHEME, 1952 (Paragraph 34)


AND
 THE EMPLOYEES’ PENSION SCHEME, 1971 (Paragraph 19)
Declaration by a person taking up employment in an establishment in which the
Employees’ Provident Funds & Employees’ Pension Scheme enforce

I Son/ wife/ daughter


(Name of Employee) ofSh.
do hereby solemnly declare that :-

(a) I was employed


in M/s (Name and Full Address of the immediate previous employer)
and left service prior to that, I was
on (Date of leaving with immediate previous employed in
employer)
fro to
(Name and Full Address of the second last  m
employer, if any) (Date of joining & leaving with second last 
employer, if any)

(b) I was member


of  (Name of PF Trust / Address of PF Office of immediate previous employer )
Provident Fund and also/but not* of the fro to
Pension Fund m
(Date of joining & leaving with immediate
 previous employer) .
and my account number (s)
was/were (PF No. with Establishment Code of immediate
  previous employer)
I have / have not* withdrawn the amount of my Provident Fund/Pension Fund.
(c)
I have / have not*drawn any superannuation benefits in respect of my past service from any employer.
(d)
I have / have never* been a member of any Provident Fund and/or Pension Fund.
(e)
I am drawing / not drawing * Pension under EPS 95.
(f)
I am a holder / not holder * of scheme Certificate.
(g)
Scheme certificate surrendered / not surrendered *.
(h)
*Strike out whichever is not applicable.
Date
Signature or left hand
(Date of joining of  thumb
employee)
impression of the
employee
(To be filled in by the employer only when the person employed had not already been a
member of the Employees Provident Fund)
Shri/Smt is
(Designation with Co.)
. (Name of Employee) appointed

1 of 2 06-Jul-22, 5:11 PM
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