Familycare Consumer Private Limited

508, C S Nayudu Arcade, 10/2 Old Palasia,

Indore (MP) 452001

** Joining Form **

Applied Post: _____________________________________________

Name: ________________________________________________Male/Female________

Fathers/Husband Name: ____________________________________________________

Date of Birth: __________________ Marital Status: ___________ Blood Group: ______

Aadhar Card No: _______________ PAN No.: ______________Bank Name________________

IFSC Code: - ________________ A/c No. ________________

Mobile Number: _________________ E Mail Id: _____________________________

Present Address Permanent Address

Educational Details

S. No Degree University From To Specialization

1

2
3

5
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Family Details

S No Name Date of Relation Mobile Number Adhar Card Number

Birth
1

Employment Details (Last Three Organisation)

Organization Name Designation From To Last Drawn Reason for Leaving

CTC

Payment of Dues :
DECLARATION AND NOMINATION FORM
I, hereby nominate the following person/s mentioned below in event of my death to receive the amount
payable to me under the following schemes of Familycare Consumer Pvt Ltd of which I am a member, in the
proportion indicated against the name.
(If applicable)
UAN Number-
ESIC Number
S. No Scheme Name & Address of Date of Birth Relationship % of Benefit
Nominee of Nominee with employee
1 Provident Fund

2 ESIC

3 Full & Final Settlement

Date Signature of Employee

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References (2)

Reference with Address & Mobile Number (1) Reference with Address & Mobile Number (2)

Declaration :
I hereby declare that the above statement made in my application form are true, complete and correct to
the best of my knowledge and belief. In the any information being found false or incorrect at any stage, my
services are liable to be terminated without notice.

Date : Signature :

Place : Name :

Mobile No. :

** TO BE FILLED BY HR **

Offer Designation :______________________________ Department :_____________________

Emp.Code :___________Salary Offered :_______________Date of Joining :__________________

ESIC Number :_________________________UAN No. :__________________________________

HR Department