Joining Check list

Employee Name: Emp. No:

Designation: Department:
Date of Joining: Qualification:

Sr. Particulars Received/ Not Remarks

No Received
1 Photographs (6 Nos.)
2 Employee Joining form
3 PF Form
4 ESIC Form
5 Gratuity Form
6 SBI Bank Form
7 Police Verification
8 Copy of Driving Licence
9 Copy of PAN card
10 Copy of Aadhar card
11 Copy of Light bill/ Telephone bill/ Rent agreement
(In case of Rental House)
12 Copy of SSC Mark sheet
13 Copy of HSC Mark Sheet
14 Copy of School Leaving Certificate
15 Copy of Degree Certificates
16 Past Working Experience Letters
17 Last Working Relieving Letter/ No Due Certificate
Bank Details: Do you have SBI Bank / IDBI Bank Account? Bank Account Number
If yes, Give details. Submit Cancel cheque or Bank
Statement with this Documents.
For Office Use only
Bank Account Udan Software PF & UAN Number
Opening Formalities Entry Entry Generation
PF Number: UAN Number
ESIC Number: Uniform P T I Card Photo
Checked by: Verified by:
 Chartered Speed Ltd
Joining Form

Name: ________________________________________________

Post Applied for: _______________________________________

Department: __________________________________________ Photo

Date of Joining: ________________________________________

Company: _____________________________________________

Personal Information:

Full Name: ________________________________________________________________

(Surname) (Name) (Father’s Name)
Permanent Address: ________________________________________________________
__________________________ City: _________________________
State: ______________________ Postal Code: __________________

Present Address: ________________________________________________________

_______________________ City: _____________________________
State: ____________________ Postal Code: ____________________
Religion: ___________________
Mobile Number: ____________________ Resident Number: _____________________
Mail ID: ________________________________________________
Date of Birth: _______/_______/_______/
DD MM YYYY
Blood Group: _______________________
Marital Status: Married Unmarried Divorcee
If married, mention Marriage Date: __________________
PAN No: ________________ License No: ______________ Aadhar No: ______________
Language known: Just mark in box

Language Reading Writing Speaking

Gujarati

Hindi

English

(Other)

Extra-curricular activities / Hobbies:

_________________________________________________________________________
_________________________________________________________________________
Academic details:
Passing
Education School/College Board/University
month Percentage
Qualification Name Name
&Year

SSC

HSC

Graduation in

__________________
Post-Graduation in

__________________

Other

Any Special Achievement:

_________________________________________________________________________
_________________________________________________________________________
 Family Details:
Relationship
Date of
Name with Occupation Remarks
Birth
Candidate

Work Experience: Start with your last Organization

From: To: Last Reason for
No Name of Organization Designation
Month/Year Month/Year Salary Leaving

Please give reference details of your previous last two organization. References can be
checked to get your work feedback from the organization as a part of joining process.

Name of Organization Reporting to Designation Mobile Number & Mail ID

Emergency Contact Details (Give first preference to your family members)
Organization will contact to above persons in case of Medical or any other emergency so be
specific in these details.

Reference 1:
Name of Person

Relationship with person

Address

Mobile Number

Reference 2:
Name of Person

Relationship with person

Address

Mobile Number

I hereby declare that the information given above are true to my knowledge and abide
and assure that at any point of time if I found guilty, the company has full right to take
action against me.

Name: _____________________________ Signature: ______________________

 FORM ‘F’

[See s u b -r u le(1 ) of r u le 6 ]

No m in at io n

To……………………………………………………………………………………………………

[Give h ere n a m e or d es cr ip tion of t h e es t a b lis h m en t wit h fu ll a d d res s ]

I, S h r i/ Sh r im a t i/ Ku m a r i…………………wh os e p a r ticu la r s a re given in th e

s t a tem en t b elow,
[Na m e in fu ll h ere]
h ereb y n om in a te t h e p er s on (s ) m en tion ed b elow t o receive th e gr a t u it y p a ya b le
a ft er m y d ea th a s a ls o t h e gr a t u it y s t a n d in g t o m y cred it in th e even t of m y
d ea th b efore t h a t a m ou n t h a s b ecom e p a ya b le, or h a vin g b ecom e p a ya b le h a s
n ot b een p a id a n d d ir ect t h a t t h e s a id a m ou n t of gr a t u it y s h a ll b e p a id in
p r op or tion in d ica ted a ga in s t t h e n a m e(s ) of th e n om in ee(s ).

2. I h ereb y cer tify th a t th e p er s on (s ) m en tion ed is a / a r e m em b er(s ) of m y

fa m ily with in t h e m ea n in g of cla u s e (h ) of s ect ion (2 ) of t h e Pa ym en t of
Gr a t u it y Act , 1 9 7 2 .

3. I h ereb y d ecla re th a t I h a ve n o fa m ily wit h in t h e m ea n in g of cla u s e (h ) of

s ection (2 ) of t h e s a id Act .

4. (a ) My fa t h er / m ot h er / p a ren t s is / a r e n ot d ep en d a n t on m e.

(b ) m y h u s b a n d ’s fa t h er/ m ot h er / p a ren t s is / a r e n ot d ep en d a n t on m y
h u sban d.
5. I h a ve exclu d ed m y h u s b a n d fr om m y fa m ily b y a n ot ice d a te t h e …… to
t h e con t rollin g a u t h or it y in ter m s of t h e p r ovis o t o cla u s e (h ) of s ect ion 2
of t h e s a id Act .

6. Nom in a t ion m a d e h erein in va lid a tes m y p r eviou s n om in a tion .

No m in e e (S )

Na m e in fu ll Rela t ion s h ip Age of n om in ee Pr op or tion b y

with fu ll a d d res s with t h e wh ich th e
of n om in ee(s ) em p loyee gr a t u ity will b e
s h a red
1.
2.
3.
s o on .

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 S t at e m e n t
1. Na m e of em p loyee in fu ll
2. Sex.
3. Religion .
4. Wh et h er u n m a r r ied / m a r r ied / wid ow/ wid ower .
5. Dep a r t m en t / Br a n ch / Section wh ere em p loyed .
6. Pos t h eld with Tick et or S er ia l No., if a n y.
7. Da te of a p p oin t m en t .
8. Per m a n en t a d d res s .

Villa ge… … … … … … ..Th a n a … … … … … … … .S u b -d ivis ion … … … … … … Pos t Office…

Pla ce S ign a tu re/ Th u m b im p r es s ion

Da te of t h e em p loyee

Decla ra tion by w itn es s es

Nom in a t ion s ign ed / th u m b im p res s ed b efore m e.

Na m e in fu ll a n d fu ll S ign a tu re of wit n es s es

1. 1.
2. 2.

Pla ce
Da te

Certif ica te by th e em p loy er

Cer t ified t h a t t h e p a r t icu la r s of t h e a b ove n om in a t ion h a ve b een verified a n d

r ecor d ed in t h is es t a b lis h m en t .

E m p loyer ’s Referen ce No., if a n y

S ign a tu re of t h e em p loyer /
Officer a u th orized

Des ign a t ion

Da te Na m e a n d a d d r es s of t h e
E s t a b lis h m en t or r u b b er s t a m p
t h ereof.

Ack n ow led gem en t by th e em p loy ee

Received th e d u p lica te cop y of n om in a t ion in For m ‘F’ filed b y m e a n d d u ly

cer t ified b y t h e em p loyer .

Da te S ign a tu re of t h e em p loyee

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www.hrsolution.co.in

FORM 2 (REVISED)
Nomination and Declaration form for Unexempted/Exempted Establishments

Declaration and Nomination Form under the Employees’ Provident Funds and Employees’ Pension Scheme
(Paragraphs 33 & 61(1) of the Employees Provident Fund Scheme, 1952 and Paragraph 18 of the Employees’ Pension
Scheme, 1995)

1. Name (in BlockLetters) : …………………………………………………………………………...

2. Father’s/ Husband’s Name: : …………………………………………….…………………………….

3. Date of Birth : ……………………………………………………………………..……

4. Sex : ……………………………………………………………….…………

5. Marital Status : …………………………………………………..……………………...

6. Account No. : ………………………………………………………………………

7. Address: Permanent: …………………………………………………………………………

……………...………………………………………………………….

Temporary: ……………………...…………………………………………………

………….……………………………………………………………..

8. Date of Joining : ……………………………………………………………………….

PART- A (EPF)
I hereby nominate the person(s)/ cancel the nomination made by me previously and nominate the person(s) mentioned
below to receive the amount standing to my credit in the Employees’ Provident Fund, in the event of my death.

Name of Address Nominee’s Date of Total amount of If the nominee is a

nominee/no relationship Birth share of minor, name &
minees with the accumulation in relationship & address
member Provident Fund to of the guardian who
be paid to each may receive the
nominee amount during the
minority of nominee
1 2 3 4 5 6

1. *Certified that I have no Family as defined in para 2(g) of the Employees’ Provident Fund Scheme, 1952 and should I
acquire a family hereafter the above nomination should be deemed as cancelled.
2. *Certified that my father/mother is /are dependent upon me.

* Strike out whichever is not applicable. Signature or thumb impression of the

subscriber
 PART B (EPS) (Para 18)
I hereby furnish below particular of the members of my family who would be eligible to receive widow/ children pension in
the event of my death.

S No. Name and Address of the family member Date of Relationship with member
Birth
Name Address
1 2 3 4 5

1.

2.

3.

4.

5.

**Certified that I have no family as defined in para 2(vii) of Employees’ Pension Scheme, 1995 and should I acquire a
family hereafter I shall furnish particulars thereon in the above form.
I hereby nominate the following person for receiving the monthly widow pension (admissible under para 162(a)(i) and
(ii) in the event of my death without leaving any eligible family member for receiving pension.

Name and Address of the Nominee Date of Relationship with member

Birth
1 2 3

Date :…………………….. Signature or thumb impression of the subscriber

**Strike out whichever is not applicable

CERTIFICATE BY EMPLOYER

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 entries/entries
been read over to him/her by me and got confirmed by him/her

Place :………………………….. ……………………………

Signature of the employer or other Authorized Officers of

the Establishment

Destination …………………………………

Date the ………………………………

 DECLARATION FORM FORM - 1

Employer's Code No.

(A) Insured Person's Particulars (B) Employer's Particulars
1 Insurance No. Day Month Year
10. Date of
Name Appointment
2
(in block capital)
Father's/
3 11. Name & Address of the employer
Husband's Name
DD MM YY 5. Martial Status M / U / W
4 Date of Birth
6. Sex M / F
7 Present Address 8. Permanent Address

________________________________ ______________________________

________________________________ ______________________________ 12. In case of any previous employment

please fillup the details as under:-
________________________________ ______________________________

________________________________ ______________________________ Previous Ins. No.

Pin : Pin : Emplrs. Code No.

e-mail address e-mail address 11. Name & Address of the employer

Branch office: Dispensary :

(c) Details of the nominee u/s 71 of ESI Act1948 / Rule 56(2) of ESI (Central) Rules 1950 for payment of cash benefit in the event of death
Name of the Nominee Relationship with insured person Address

I hereby declare that the above particulars have been given by me and are correct to the best of my knowledge and I belief. I also under take to
intimate to the corporation any change in the membership of my family within 15 days of such change having occured.

Counter Signature of the Employer

Signature with Seal Signature / T.I. of I P

(D) FAMILY PARTICULARS OF INSURED PERSON

Sl. Relationship with Whether residing with If No, State place of

Name Date of Birth
No. insured person him/her or not Residence
YES / NO TOWN STATE
1

ESI CORPORATION
Temporary Identity Card Valid for 3 months from the date of appointment
Name

Ins. No Date of Entry

Father's/ (Space for photograph)
Date of Birth
Husband's Name
Branch Office Dispensary

Name, Address &

Code No. of the
employer

Validity
Dated Signature / T.I. of I P Signature of B.M. with Seal
 INSTRUCTIONS

1 Submission of Form 1 is governed by regulations 11 & 12 of ESI (General) Regulations, 1950

2 *Family* means all or any one of the following relatives of an insured person namely:-
(I) a Spouse (ii) a minor legitimate or adopted child dependent upon the I.P.: (iii) a child who is wholly dependent on the earnings of
the I.P and who is (a) receiving education, till he or she attains the age of 21 years (b) an un married daughter; (iv) a child who is infirm
by reason of any physical or mental abnormality or injury and is wholly dependent on the earnings of the I.P. so long as the infirmly
continues; (v) dependent Parents

3 Identity Card is Non - Transferable

4 Loss of Identity Card be reported to Employer / Branch manager immediately

5 Submission of false information attracts penal action under section 84 of ESI Act, 1948

6 This form dully filled in must reach the concerned Branch office within 10 Days of appointment of an employee. Delay attracts penal
action under section 85 of the Act, against the employer

7 As an insured person you and your dependent family members are entitled to full medical benefit from today itself. The other benefits
in cash include (1) Sickness Benefit (2) Temporary Disablement Benefit (3) Permanent Disablement Benefit (4) Dependents Benefit and
(5) Maternity Benefit (in case of women employees) subject to fulfillment of contributory conditions

8 For more details contact website of ESIC at www.esic.org.in or contact Regional office or Branch office

FOR BRANCH OFFICE USE ONLY

1. Date of allotment of Ins. No.

2. Date of issue of T.I.C :

3. Name / No. of Disp. :

4. Whether reciprocal Medical arrangements involved, if yes, Please indicate

Signature of Branch Manager

Sl. Relationship with Whether residing with If No, State place of

Name Date of Birth
No. insured person him/her or not Residence
YES / NO TOWN STATE
1