Alembic Pharmaceuticals Ltd.

- Provident Fund
BARODA - 390 003
APPLICATION FORM FOR THE WITHDRAWAL FROM PROVIDENT FUND A/C
Particulars of applicant
Emp no :___________

p.f. No : ____________
A)
Full Name _____________________________________________________________Tel. No.________________

Permanent Address: ____________________________________________________________________________

Name of Department :___________________________________________________________________________

Permanent or _________________________________Period of __________________Rate of _________________

Temporary in Job: _____________________________Service:___________________Salary: ________________

(Monthly)

Amount of Withdrawal: Rs.____________________________Reasons for withdrawal_______________________

Amount of Monthly Repayment Installment: Rs._______________ Withdrawal made or Not:__________________

If yes, when________________________& How much Amount __________________Balance Amount of Previous

Withdrawal as on today: ______________________________________month in which Last deducted for Previous

Withdrawal ______________________________________

Does Applicant has taken any Nonrefundable loan _________________if yes, How much Rs.__________________

Which reasons ________________________________________________

Applicant’s Signature: _______________________________________________Date:_______________________

Signature of Recommending Officer

Of the Department: _________________________________________________Date:_______________________

(B) Particulars of office

Amount of Applicant’s Provident Fund Balance Rs. ____________________approx (Applicant’s own contribution)
Date:
Remarks :

Recommending Officer for sanction: ____________________________________________Date:______________

Sanctioning Trustees: ___________________________________________________________________________

1. I have received the amount or Rs.________________________ (Rupees

________________________________________) which has been sanctioned of withdrawal from my
Provident Fund Amount .
2. I agree to repay Rs. ______________________________as Monthly installment for the repayment of my
above said withdrawal amount and I authorize M/s. Alembic Ltd. To deduct the monthly repayment
installment directly from my salary. Further I agree to pay 1% more interest on the amount of withdrawal
than what is credited to my provident fund A/c.
3. in case I do not repay the amount withdrawn from my P.F. you are hereby authorized to recover the same
with interest accrued on the amount, from my Provident fund account.
_____________________
Applicant’s Signature
Witness: ______________________________

Date :______________________________ Date :________________