NON- EMPLOYMENT DECLEARATION CERTIFICATE

1. Shri/Smt. …………………………… RAKESH KUMAR ………………………………………………………………………….

2. S/O ……………………………KARTAR NATH ……………………A/C No. ……………..
3. Affirm and declare that I was last employed …………………………………………………………………………
………………………………………………………………………………………………… after leaving service of
the aforesaid factory /Establishment, I have not employed in any factory/ Establishment
Covered by the Employees Provident Fund Act for continuous period of six month immediately
Proceeding the date of my application of final withdrawal

Signature or left Thumb impression

Dated:-

Attested

(Dated Signature with official Seal)

EX. Employer/ A Gazetted Officer/
A Municipal Councilor /Oath Commissioner
Magistrate /notary/ M.P.

……………………………………………………………………………………………………………………………………………………

Name of the member …… RAKESH KUMAR S/O KARTAR NATH …………………………………………..

A/C NO. MONTH EMPLOYEE’S EPMLOYER’S TOTAL REFUND WITHDRAW

AND YERS SHARE SHARE
1
2
3
4
5
6
7
8
TOTAL -
RUPEES

Signature of the Employer/Manager with Seal