member 1.b)Name of the .......................................................... claimants 2.DOB 09-09-1990 3.Fathers Name KRISHNA MURTHY 4.Husbands Name 5.Name & Address of establishment in which 6th Floor, BMTC Commercial Complex, 80 ft Road, the employee was last Koramangala, Bangalore, Karnataka. PIN - 560 095 employed:- 6.Code No and Account Region/SRO Code K N B N G No. Estt. Code No BG/BNG/0035224
PF No. BG/BNG/0035224/000/0813724
7.Reason For Leaving
Service I got a great opportunity other company 8.DOL 08-09-2018 9.DOJ 01-10-2016 H No;106 Moulali Venkata Siva Sai Tower 10.Full Postal Address ,,TLG,001-500040 Sh/Smt./Km .......................................................... S/o,W/o,D/o .......................................................... Pin Code 500040
11.Are you Willing to accept scheme (a) (b) (a) (b)
Certificate in lieu of withdrawal benefits Yes No
12.Particulars of Family(Spouse & Children & Nominee) Type Name Date of Relationship with Name of the guardian : Minor Birth member of (a)Family: (a)Nominee: 13.In Case of death of member after attaining the age of 58 years without filing the claim:- (a)Date of death of the member: (b)Name of the claimant(s) and relationship with the members: 14.MODE FOR REMITTANCE[PUT A TIC IN THE BOX AGAINST THE ONE OPTED] a)By postal money order at my cost to address given against item no.7 b)Account Payee cheque sent direct for credit to my SB A/c(scheduled bank) under intimation to me S.B.Account No 44411352450 Name of the Bank NEFT Branch Jubilee hills Full Address of the Branch 8 - 2 - 293 82 A 646 A, Ground Floor,, Hyderabad IFSC Code SCBL0036090
15.Are you availing pension under EPS -95?
If so indicate:PPO No.........................by whom issued...............................
CERTIFIED THAT THE PARTICULARS ARE TRUE TO THE BEST OF MY
KNOWLEDGE Date Signature or left hand thumb impression of the member /claimants(s)