sumenfindiagn Composite Declaration Form -11 (oben iy the eplape for fate reference) EMPLOYEES’ PROVIDENT FUND ORGANISATION Employees’ Provident Funds Scheme, 1952 (Paragraph 34 & S7) & Employers? Peusioa Scheme, 1995 (Paragraple 24) (Decteraton by prentling wp emploicat is sey casa! 08 which EP Seen, 1952 nd for EFS 1995 apple) T = if i 1 1 | Nome of tie member | mee | ae Date of Birth: (DD /MM/Y¥¥Y ) ‘Gender: (Male/Female/Transgender) ‘Marital Status: (Married/Unmarried/Widow/ Widower Divorces) |) Mobile Nox __ | Present employment details: | 27 | Ducting ine tres eblihment (DDIAUYYYY) | | RC eta (tach slr ae copies a aang RVC | |) ak eso Wo-? | 8 |b) HSCode ofthe brane: 3) RADAR Naber Pence Accoual Waar AN) iTavaaile | Waster eariers meme of Fployes" Peon Font Sion, is ‘Weiler ciara naira Raiagess Pein Ses 195 hoy Geta: [if Yes to9 ANDIOR 10 above) Umcicapied Uninensi | PF Anant | Dab afjoming [ Daofexkt PRO Nambar | Re Accut | Nonber | (DM | @DAow (GFssoed) | Couribtory amber yyy | yyYy, Paved (sch Days ic Py Naw ‘ofexti [~ Scheme EPS Ave | joining | (DDIM | Ceniieste | Contibutory Number | (DDMAY | YYYY) | No. Cif | Period (NCP) Y¥YY) | issued Be | 2 | 2) International Worker B1) Corti tat th partons are ts tothe best of my knowiedge, 2) authors EPFO wo wse my Aadhor for vritiation/auheticationl-KYC pupose for vrvce delivery. 2) Kindly trasser he fons and service details, if appicbls, from te provions PF accounts cls! above tothe preset PR. ‘Account Taman Aad verified emgoyee in my provers PE Accoun® 4 Incase of chang in sbove desl, he game wil be intimated to employer a he cars Signature of Meabor 1B. Incase the peson was earlier ota menibr of PF Scheme, 1952 aod EPS, 1995 Please ‘Tiek the Approptiste Option: : “The KYC det of th sbowe member inthe UAN datskase 2 imverot boon pleaded 2 Haveboon uploaded but not appre 11 Have been uploaded and proved with DSCe-sign, In case the psn ws ear a member Of EPF Scheme, 1952 ood EIS, 1995: + Please"Tiek the Appropriate Options 12 The KYC details of the above member in dhe UAN database lave boon approved with E-sign/Digital Signatare Cente and cansfir request ha boon generated on pot. 2 “The previous Account ofthe member snot Aadkar vied and lence physical taster fem shall boiled, Date: Signature of Employer with Seal of Esublishent ‘Auto taster of previo PF account would be possible i espet of Aaar verified employes onl. Other exployses are quest to Se pysial claim (Forrol3) fer wane of accomnt om ths provieusetalishnen