FORM No 5A Date : 04-Jun-2017
EMPLOYEES' PROVIDENT FUND SCHEME 1952 (Please refer Para 36A)
EMPLOYEES' PENSION SCHEME 1995 (Please refer Para )
EMPLOYEES' DEPOSIT LINKED INSURANCE SCHEME1976 (Please refer Para 10)
(Ist RETURN OF OWNERSHIP AFTER ONLINE APPLICATION FOR CODE NUMBER)
[THIS FORM 5A HAS BEEN GENERATED BY ONLINE FILLING/ UPDATION OF FORM 5A THROUGH ECR LOGIN
OF EMPLOYER. APPLICATION NUMBER IS 1114346949.]
Code Number : MRNOI0027554000
1. Name of Establishment : E PACK POLYMERS P LTD
2. Code Number of the Establishment under EPF Scheme 1952 : MRNOI0027554000
3. Postal address of the Establishment and its branches : 61-B, UDYOG VIHAAR,KASNA ROAD,NOIDA, B 13,14
ECOTECH I EXT GR NOIDA, GREATER NOIDA, GAUTAM BUDDHA NAGAR , UTTAR PRADESH - 201306 [Please
4. Industry or business in which engaged : PLASTICS PRODUCTS
5. Date of commencement of business : 01/01/2000
6. Date of closure by previous management : N/A
7. Whether run by owner or lessee : Run by Lessee
8. Particulars of owners :
S. Name Date of Status Father's Name Residential Address Position
No. Birth Date
1 Mr. SHIV KUMAR 07/11/1973 MANAGER M S TOMAR I 427 ALPHA 2 01/07/2010
TOMAR HR GREATER NOIDA
9. In case on lease, particulars of lessee :
S.No. Name Date of Birth Father's Name Residential Address Position
Date
1 Mr. SANJAY SINGHANIA 26/07/1974 D D SINGHANIA D 144 SECTOR 47 NOIDA 01/01/2000
10. If registered under Factories Act, particulars of Manager or occupier :
S.No. Name Date of Status Father's Name Residential Address Position
Birth Date
11. Particulars of persons mentioned above who are incharge and responsible for conduct of business of the
S. Name Date of Status Father's Name Residential Address Position
No. Birth Date
Date: Signature of employer _____________________________
Name of Employer _____________________________
Designation of Employer _____________________________
Seal of Establishment Mobile number _____________________________
Application Number : 1114346949 Page 1 of 4
Code Number : MRNOI0027554000
Signature of employer at serial number of Owners details, if more than one employer.
Signature of remaining employers:
Signature Signature
Name _____________________________ Name _____________________________
Signature Signature
Name _____________________________ Name _____________________________
Note: Any change in the information given above should be intimated in writing to the Regional Commissioner within
fifteen days of such change by registered post and in prescribed manner.
Application Number : 1114346949 Page 2 of 4
Code Number : MRNOI0027554000
ANNEXURE - I
Details of Branches of the Establishment
S.No. Branch Name Address State - Pincode Branch Type Employees
1 E PACK POLYMERS B-13,14 ECOTECH - I UTTAR PRADESH NOT AVAILABLE 150
PVT LTD EXT KASNA GREATER - 201308
NOIDA, GAUTAM
BUDDHA NAGAR
ANNEXURE - II
List of Branches having Separate/ Sub Code Number
Application Number : 1114346949 Page 3 of 4
Code Number : MRNOI0027554000
SPECIMEN SIGNATURE CARD
To be submitted with all documents after the Code number is allotted through the online application.
FULL NAME OF THE AUTHORISED SIGNATORY __________________________________________________
Name of Establishment : E PACK POLYMERS P LTD
Address of the Establishment : 61-B, UDYOG VIHAAR,KASNA ROAD,NOIDA, B 13,14 ECOTECH I EXT GR NOIDA,
GREATER NOIDA, GAUTAM BUDDHA NAGAR , UTTAR PRADESH - 201306
Code Number of the Establishment : MRNOI1104013000
STATUS OF THE SIGNATORY : # EMPLOYER / AUTHORISED SIGNATORY
# Strike whichever is not applicable
SPECIMEN SIGNATURE 1. _____________________________
2. _____________________________
3. _____________________________
SPECIAL INSTRUCTION, IF ANY _______________________________________________________
SPECIMEN SIGNATURE OF Mr/Ms _______________________________________________________ ATTESTED
Signature of employer _____________________________
Name of Employer _____________________________
Designation of Employer _____________________________
Seal of Establishment Mobile number _____________________________
[ ] Please tick if "Not Applicable" due to upload of digital signature
To be submitted separately for each Authorised Officer, if more than one.
Not to be submitted in this format if the employer after allotment of code number has uploaded digital signatures of the
Authorised signatories.
In such case the letter generated from the portal after uploading the digital signature(s) to be sent.
In case of upload of digital signature, when page (6) specimen signature card is not applicable, strike this, but keep as
enclosure to the form 5A.
Application Number : 1114346949 Page 4 of 4
Code Number : MRNOI0027554000
