‘FEAT 2 (Garda) wri 2 (eifBa) Form - 2 (REVISED) am fide a 7 ye 7 Ramen / arte deraidt OYE wT / Be wre Waa 8g amie ote creer wrt NOMINATION AND DECLARATION FORM FOR UNEXEMPTED / EXEMPTED ESTABLISHMENTS arhert afte fate a oetent fight aa chor siete oeoarr order orden a ae Preerarer AGT art afte AR we ated te wee seria cio wa arate ort | Declaration and Nomination Form under the Employees’ Provident Fund & Employees’ Pension Scheme (orton after Prete PARR ahora Hue UT TTT ay 4 0) T ‘wtenet Pgh Sot MINT RG ST MTSE 30 AT ee) (orient after FR wr 1052 & fer 33 sheet (1) we ‘stent ders eee 1995 or ter 18) (Paragraph 33 & 61 (1) of he Employees’ Provident Fund Scheme, 1952 & Paragraph 18 ofthe Employees’ Pension Scheme, 1985) 4, Tie (TS weta) 6 ataw a (pore met H) wer ior ‘Nam (in bce Lets) count. 2. ats / wiht ate 7. Ren / WT Address fret / of ear car / wart / Permanent. Fatherstusband Name : 3. PTE /o AV Date of Bich oe eon, ‘argent / eae Temporary 8. Rreréteh Ret ‘tate Raft Maral Status PART -A(EPF) a1 — & (arfarét afaeafafa) a wore ante am fen ote ort ont aed ae Pde ee oer, A anda antter/emer a PeToeT Sao Ry A TT aT oe ra a Pr raion Fed ee, cea are are eI iia ET aT, rR Bre A aft (ah) wt aa / eee over & ate eA ey a TA cer A A wear ales Cet) wore ad eT aed afta AT aftr a wet Ry aha eT EI ‘hereby nominate the person(s)cancel the nomination made by me previously and nominate the person(s), mentioned below to receive the amount standing tomy eredtin the Employees’ Prowidert Fund, in the event of my death Prats at 7 = arent sate | osetia [Pitta after jae | Ritts a ox oer ate ee Te = Prin ett | omnes [Rae ote ges | Seer at eeu a et ae / Ret ‘cross itd | Daleot [rem am teres | Petes ether oem ware a0 fered rate) 8 [ome ame Ri eft @ | ete AER Recaro Nave oft eae fete eta chr | sen. 2 afta he Bom ae rerinees Nominee's fra octet en | ee ead athe eto lauren eh a! ano ora os oe my deo ba re a Fra oe pls es= nansanpt omni gosh roma he may mene he sou ng a a) (Osanna wen one scar1.9 ate ce oh ert oe fig AR ae et ¢ ) seeaAte Se a a I Ses he a om eet es sfterers area ete am, Préea ee * softer Rar care & fs tee ser PAA Ter 1052 2H aon 2 (@) @ argu Aer ate after Te E ste Fes vere ofS Am whe Raw Fe & at ees Tse HE TAH TT! * Certified that | have no family as defined in para 2(a) of the Employees’ Provident Fund Scheme, 1952 and should | acquire a family hereafter the above nomination should be deemed as cancelled. 2 sam omg / afta renee seeigr om / sree + senfhe lrer re & fe AE Re/ eT Gee on 1 * Certified that my father / mother is/are dependent upon me. @ Beerh ae a aE cA. ‘wayerh TE see sreaTaT SAT ‘Gt ary a8 & Ba we Z ara YeTOrt owt zp on Pe Strike Out whichever is not applicable. Signature or thumb impression of the subscriber amt @ (Prof das atora) /art & (@. &. fA) / PART -B (EPS) uftade 18/2 48 / (Para 18) Ban ene weet Ps ea ee Pag eins Ra ot at oa / A ait dea Te, ae an 3 ah ater & eel a Reem Ate ae we Cot AE ga ee A eer fae / os See ot oa Bh ‘Thereby furnish below particulars of the members of my family who would be eligbe to recelve widow / children Pension in the event of my ceath, ge | agediy enc a of wate aaa oe eon] SRL TH OE al ore dare oe S.No. | Namo & Address ofthe family member sens ato Bier_| Relationship wih te member 1 2 3 4 & 1 2 a 1 a eto Pgh te, ory tage et eb 3) wet Per ran aR gga ener ah yee HT TRY RE re Ee mee whe ai A carer TT BA. * poate 6 aed fo Ge Re Sa ase eel Bat 2) 2 gare Pee cea @ ste oR ges Ger Aer ahs Gare eet 8 A Sa or A oer ahr He woe * Certified that | have no family as defined in para 2(vii) of Employees’ Pension a 1995 and should I acquire a family hereafter I shall furnish particulars thereon in the above form. (© scat wth on snesA aan wa AGE wat / Set A ber 96() (@) (i) sath (li) em seis He Gey Sars eT GT rear gett TAP Sater MA HAR BRT wee TE, ES get a ar 6) C0) ae 0) ai tar tere Her A rg af rer Gre sftite ter wo oetaer Rar a aE ae | hereby nominate the following person for receiving the monthly ia pension amis under pare 16(2) (2) ()& (hin the event of my death without leaving any eigble arly member for recsving pension, arePrterord iq oni oar ont wore aa ATT ater a ATF of Te weft Fe SW ay Name & Address of the nominee Date of Birth _| Relationship with the member, amttar / Penis / Date © geraers aaaR BET CT. + ot ary ad @ ware 8 aE TA saat stro Tat * Strike out whichever isnot applicable. aera & BE sea SEB wT Pre Signature or thumb impression of the subscriber areera wares (Praleer ge WAeTTa) / CERTIFICATE BY EMPLOYER seaftre areas at ft area eels ori wes atte ah / ait / ge ah attr rere war Peerage earch TEER. / TRA arava asa sOPy / ae Sea Te HS WE SA ome / Sea sirearay Sar wT ATA oT spats far orem Ps Saar wi ser arate w/a ge Sot SO wea A are @ AR wa eee /aiTB am Peeve aren 81 Ger wea wh ver 1 RR ae ara A arr aah ag ate we GAA BE BI Certified that the above declaration and nomination has been signed /thumb impressed before me by Shri/ Smt. Kum, —__ employed in my establishment after he/she has read the entry / entries have been read over to him / her by me and got confirmed by him / her. om wr wearer & Pradeen srerar sage safdentt & eens Place : ‘Signature of the employer or other authorised officers of the establishment Designation / TA" a ‘Beery are anf fever we fre Dated the amet / duet or ae othe oer set Gah wes shee Name & Address of the Factory / Establishment or Rubber Stamp thereof (maps 2 (gets) Reger bea et) (ae nen Pees seme: E) (This form's avaaba ea of cost) (© scat wth on sanevars varie afta fates Al AIRPORT SERVICES LIMITED afer feraror PERSONAL DATA TAN (Fea wea) ane a a (Surane es: a Fetes /attraten Father Name: Tamer ORS ‘ear at RT FAS. Fe Local Address: es. Te, wth STD Code ert vt tater. Permanent Adsress : opie No. wa sien yee e Native Place with Adress = Ema Nationality, Rekciog Sa ser were mt oy ee RR) ORAS eT a FTE ‘- Fav 7 Ider Tonge: 7 bailesiahiater >> hia wa rt Languages Known: aaa vin ‘Frere art arate ated & are cert sree Ga oe ‘Name of dependents Relatonshin Place of residence ie, wth the employe or dlsevtere i] @ ®) a ‘Frweam deh ar 0g eT VT Name and Address of next of kin tn Relationship Contac No. ere 8 start BR ae eal Roative employed wih he Company aH ae ‘fo 8 fre ve ae Name Relationship Position held in the Company waar Fen Ped woh re ove} aod ae at re rh BA ea fe en ge wh free, Fea ere a8 re Fg oR ‘aero ae a eH RR wed re ch A GET TA eae a UR ae Hera Te age Tce og wa wea a ore, Concealingfurishing incamect infornafon by the candidate about his near relationship wih an ‘of the Company woul be deemed as conceatnent of facts whch may disqualify him for selection and if at a ubsequat ‘stage the fact is know, il would be deemed as a serious misconducl and deall with severely in aoe wh be pons ceteris A irda AQUALIFICATIONS wae aH fest feetearsiter St seen Pre hee saat Name Degree/Diploma/Exam. Class or Distinction Year of passing bad Schoo! fetes University wit Tectnical ora chem ber Cualeatin POE (Osanna wen one scar2. BLAPPRENTICESHIP. oct sare aa Tet aT rat afta, a AER Name and adress of the Co or Fim Trode Pesied Peso Roe ae C. PREVIOUS EXPERIENCE Sara aah at dred aaa at fhe aaa Petodotsenice | fer |__Salary/on leaving ast oe aa [Name and adress of employer | —ay a Postheld = — ‘Reason for leaving Form To Basic | Alowance Bt seafina ae fe Farerfora arateraal aa sects Sere Fear ere Sars sree AF we oh a aE flo & 1 | cerify that! have not worked at any place(s) other than thatthose mentioned above wa amt arated safe a argafad arnt & wee @ fart sete arqafaa wae atte again sane Hiatt arse we ofa wreerhadeya amet a TH At 7 Ave you a member of a Scheduled Tribe as listed in The Scheduled Castes and Scheduled Trbes Lists Modification Order 1959 and Agpeable atsConsitiuton Order ? ar my 3 FOS ait eT t FarraT TAT TT ATH, HIT HET Fs WeeT WT 12011 (68) 93 Aaah. (aH) feta 10 ferrat 1993 4 fear t | ‘re you armenber of ahr Backward classe as ited inthe Goof Ina Micisy of Socal Wola No 2011688 BCO() ales September 10, 1285 | anid ) ‘Fate Cpa aH Te eT g) + Reference Please gvename BAddress): ea ary Bea Fag A ‘Ave you a Government Pensioner ? ar Sy Cara ATH aa a P ‘Were you a permanent Govt. Servant ? ara ah aca 8 fered tera fresh t 2 er wea Hl eae, Ho she Teta He How much pension do you draw trom the Govt. ? Mension ‘wlerences, number etc. of pension documents : Panto ‘Adhar Card No. Name of Bank, Branch, Account No. attach copy of blank cheque) ten: regret ee ever ee & Ps ae ae A Tae ate fret Sea ah ea oft wt | DECLARATION : the undersigned hereby declare thal he above paricuars ae tue and corect tothe best of my knowledge and belt. age ST Signature of appican (Osanna wen one scary* Al AIRPORTSERVICESLIMITED. Employee Information Sheet for ESIC (To be filled in CAPITAL Letters) rs} Particulars Details Spratt N umber 7 wom per(if staff already covered under ESIC) 5 | siation a 1 pirstName i FatherName : pusband Name(forMarriedFemale) wifeName(forMarriedMale) 7 | Dateof Birth i Gender MaritalStatus AadhaarNo fy a 43 | ResidenceAddress PermanentAddress NomineeName 15 Relation Lo Dateof Birth Aadhaar No. FamilymemberName(1) Relation Dateof Birth Aadhaar No. FamilymemberName(2) Relation Dateof Birth Aadhaar No. FamilymemberName(3) Relation Dateof Birth Aadhaar No. FamilymemberName(4) Relation Date ofBirth Aadhaar No. PANCard No.&NameasonPANCard NameasonAadhaarCard DateofAppointmentinCo. 7 ; IC). AagitontactNo, ESIC car (sa areay covered under ESI E