From 11 (Revised)

The Employee's Provident Fund Scheme, 1952

(For unexempted Establishement only)
(Paragraph 34)
The Employees's Family Pension Scheme, 1971
(See Paragraph 19) and

Declaration by a person taking up Employment in an establishment in which

the Employee's Provident Funds and Family Pension Fund Scheme enforce

I Mr. Ketul Trivedi

son /wife /daughter** of :- Mr. Vishalkumar Trivedi
do here by solemnly declare that :

(a) I was employed in M/S :- Elsner Technologies Pvt. Ltd.

address 305,306 Iskon Center, Shivranjani Cross Road, Satellite, Ahmedabad - 380015
As newly appointed for the frist ever

(b) I was member of :- Not a member as PF is Not Applicable

Provindent Fund and also / but not of the ------N.A.------ Penson Fund from
to -----N.A.----- and my account number(s) was/were -----N.A.-----
(c) I have /have not withdrawn the amount of my Provident Fund /Penson Fund. -----N.A.-----
(d) I have / have not drawn any superannuation benefits in respect of my past services from
any employer -----N.A.-----
(e) I have / have not never been a member of any Provident Fund / or penson Fund :- Agreed With (e)
(f) I am drawing / not drawing Penson under EPS 95. :- ------N.A.------
(g) I am a holder / not holder of scheme Certificate. :- ------N.A.------
(h) Scheme Certificate surrenderd / not surrendered. :- ------N.A.------
* I here by declere that I am not willing to become a member of EPF Act as My Monthly Salary exceed Rs 6500/-

Date :- 01st June 2022 Signature or left hand thumb impression of the employee

(To be filled by the employer only when the person employed had not alredy been a member of the
Emplolyee's Provident Fund)

Shri / Smt Ketul Trivedi (Name of the Employee)

is appointed as Jr. PHP Developr (Designation)
in M/S. Elsner Technologies Pvt. Ltd. (Name of the Factory / Estb.)
With effect from 01st June 2022 (Date Of Appointment)

* The Employee's monthly salary exceeds Rs 6500/- Under the EPF and MP Act.

Date :- 01st June 2022 *signature of the Employer / Manager of other Authorised Officer
* Left Thumb impression in the case illiterate male member and right hand thumb impression by illiterate Fmale member
** Strike out which is not applicable.
Delet the Portion in (a) to (h) above not applocable