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EMPLOYEES' PROVII)T NT FUND ORGANISATION
Employees'Provid€nt Funds Sr:henre, 1952 (Paragraph 34 & 57) &
Employees' Pension rir.henre, '1995 (Paragraph 24)
(Declaration by a person taking up employrnenl in any establist)ment on which EPF Scheme, 1952 and /or EPS, 1995 is appllcable)

lVorru q
,. Name ot the rnenlb(:r

QJ? Acl
Father's Ittame
-J
{Z Spouse's Name E
(Please tick whichever is applicable)

Date of Birth: ( DD / MM / YYrY

Gender: (Male/Female/'f ransgender)
) I c,

(a) EmailID:

Whether earlir:r a member of Employees' Provident Fund Scir:rrre, No

1952
Whether earlirlr a member of Employees' Pension Sr:heme, 1it95 Yes / No
Previous employnrent details: [if Yes to 7 AND/OR 8 itoove]
a) Universal Account Nurnber:

b) Previous PF Account l.lumber:

c) Date of exit frorn previous employment: (DD/MM/YYYY)

d) Scheme Certificate No (if issued) i

e) Pension F)aymerrt Ordr:r (PPO) No, (if issued)

a) International Worker: Yes /

b) If yes, state country of origin (India/Name of other counl'ry)

c) Passport No
passport to (DD/MM/WYY)I
KYC Details: (attar:h self attested copies of following KYCs)
a)_-ilnk AADunt l\ib, & x<eode-.--.---------!--
2)s Pvov
b)
c)
MDHAR Numb,3r
Permanent Account Number (PAN), if available
trti
UNDERTAKING
1) Certified thaI the particulzrrs are true to the best of my knowle tir,a
z) I authorize EPFC) to use r1]y Aadhar for verification/authentical:io r/eKYC purpose for service delivery.
3) Kincily transler the funds ilnd service details, if applicable, frorrr ,lre previous PF account as declared above to the present P.F. Account.
(The transfer wouftJ be pqssible only if the identified fiC deta,l ,rpproved by previous employer has been verified by present employer
using his Digital Signaturer Certificate)
4) In case of chanltes in above details, the same will be intimate,:J to employer at the earliest.

Date:
Place: r
Signature of Member
DrcLnnAl-roN sv pneseNr rrupLoven
A. The member Mr./t4s./Mrs. has toined on and has been allotted PF Number

B. In case lhe person was earlier not a member of EPF Scherrre, 1952 and EPS, 1995:
. (Post allotment of UAN) The UAN allotted for tlre rnember is ....'.. ,...... . ... ..'.....
. Please Tick the Appropriate Option:
The fiC details of the above member in the .lRN database
i.Have not been uPloaded
t Have beerr uploaded but not approved
I Have beerr uploaded and approverj vt'ith DSC
("i2 and EPS, 1995:
C. In case the petson was earlier a member of EPF Scheme,
. The a'3ove PF Account number/UAN of the mernlre' as rnentioned in (A) above has been tagged with his/her LIAN/Previous
Member ID as declared bY member.
. Please Tick the Appropriate Option:-
i. Th€: KyC details bi tne aUove member in the J.qN database have been approved with Digital Signature Certificate and
transfer rerquest has been generated on poftal
l As the DSC of establishment are not registererl with EPFO, the menrber has been informed td flle phYsical claim (Form-
13) for transfer of funds from his previous est;rb 'shment'

Date: Signature of Employer with Seal of Establishment