DECLARATION BY AN EMPLOYEE

I ...........................................................................................son/daughter/wife of..........................................................
resident of .....................................................................................................................................................................do
hereby solemnly affirm and declare as under :
1) That I hereby declare that all the information and documents furnished/ to be furnished by me to
DIL/DFSPL/DASMPL are reliable, authentic, true and complete to the best of my knowledge and understanding.
2) That I hereby declare that the Company reserves its right to carry out my background verification including but
not limited to verification of address, educational background, previous employer, police verification etc., either
itself or through any third party engaged for this purpose and I hereby understand to fully co-operate with the
Company for this purpose.
3) That I hereby declare that the Company may carry out background verification at any time before or after
offering me employment and I hereby undertake not to object to such verification in any manner whatsoever.
4) That I hereby agree and undertake to forthwith furnish such other information and documents as and when
required by the Company.
5) That I hereby declare and agree that in the event any information or document furnished/ to be furnished by me
is found to be false, incorrect or incomplete, the Company reserves its right to terminate my employment or take
such other appropriate action as it may deem necessary.
6) That I hereby agree and undertake to indemnify and hold harmless the Company for any loss that the Company
may suffer on account of any false information or document furnished by me or as a consequence of nonm
submission of any information or document by me as and when demanded by the Company.
7) That I hereby declare that I am currently not employed with any other person, company, firm or any other entity
and that I shall not take up or engage myself in any manner whatsoever in any personal work including but not
limited to providing any consultancy, advice etc.
8) That, there is no court case, either civil, criminal or labour cease pending for or against me in any court ofauthority
anywhere in India or abroad.
9) That the following cases are pending against me for which the decision of the court is awaited OR were registered
against me for which I was convicted and that the case is now closed.
Case Details Case No. & Date Court & Location Status

a. .................................. .................................. .................................. ..................................

b. .................................. .................................. .................................. ..................................

10) That, I have no association with any of the terrorist groups / organization nor was I a member / part of
suchorganization, which is banned by the Government of India or by an Foreign Government having
diplomatic relations with India.
11) That, I hold a valid two wheeler driving license no___________________________________________________
issued by R.T.O __________________________valid till ______________________________ copy of
which is submitted for records. (Only for rides - other to strike through the paragraph)
12) I hereby declare and agree that I will be personally responsible for any kind of stock shortage, raw material shortage,
financial losses, loss of the company assets, misappropriation of company cash happening at my allocated store/
patch/market/region. I hereby allow and authorize the management of the company to make adjustment or recovery
of any kind of losses initiated from my payable dues during my employment or after my separation from the company
from my full and final settlement with the company.

I have read, understood and accept the above declaration to be the part of my joining documentation.

Date:

Place: Signature of the Employee

1
 Payment of Gratuity (Central) Rules
FORM ‘F’
See sub-rule (1) of Rule 6
NOMINATION
To,

(Give here name or description of the establishment with full address)

_________________________________________________________________________________________________
_________________________________________________________________________________________________
I, Shri/Shrimati/Kumari ________________________________________________________________________________
(Name in full here)

whose particulars are given in the statement below, hereby nominate the person(s) mentioned below to receive the gratuity
payable after my death as also the gratuity standing to my credit in the event of my death before that amount has become
payable, or having become payable has not been paid and direct that the said amount of gratuity shall be paid in proportion
indicated against the name(s) of the nominee(s).
2. I hereby certify that the person(s) mentioned is/are a member(s) of my family within the meaning of clause (h) of
Section 2 of the Payment of Gratuity Act, 1972.
3. I hereby declare that I have no family within the meaning of clause (h) of Section 2 of the said Act.
4 (a) My father/mother/parents is/are not dependent on me.
(b) My husband’s father/mother/parents is/are not dependent on my husband.
5. I have excluded my husband from my family by a notice dated the to the controlling authority in terms of the proviso to
clause (h) of Section 2 of the said Act.
6. Nomination made herein invalidates my previous nomination.

Nominee(s)
Name in full with full Relationship with the Age of Proportion by which
address of nominee(s) employee nominee the gratuity will be shared
(1) (2) (3) (4)

2
 STATEMENT
1. Name of employee (in full) _________________________________________________________________________
2. Gender____________________________________ 3. Religion __________________________________________
4. Whether unmarried/married/widow/widower ________________________________________________________
5. Department/Branch/Section where employed____________________________________________________
6. Post held with Ticket or Serial No., if any ______________________________________________________________
7. Date of appointment_____________________________________________________________________
8. Permanent Address : Village________________________________Thana____________________________
Sub-division_____________________________________ Post Office______________________________________
District__________________________________ State __________________________ Pin ___________________

Place_________________ ____________________________________
Date_________________ Signature/Thumb Impression of the employee

DECLARATION BY WITNESSES
Nomination signed/thumb impressed before me.

Name in full and full address of witness Signature of witness

1. _____________________________________ 1. __________________________________

1. _____________________________________ 1. __________________________________

2. _____________________________________ 2. __________________________________

1. _____________________________________ 1. __________________________________

Place________________
Date)________________

CERTIFICATE BY THE EMPLOYER

Certified that the particulars of the above nomination have been verified and recorded in this establishment.

Employer’s Reference No. if any. ______________________________ Signature of the employer/officer authorised

Designation
Name and address of the establishment or
rubber stamp thereof
_____________________________________

Date)_________________ _____________________________________

ACKNOWLEDGEMENT BY THE EMPLOYEE

Received the duplicate copy of nomination in Form ‘F’ filled by me and duly certified by the employer.

Date_____________________ Signature of the employee

Note : Strick out the words/paragraph not applicable

3
 FORM NO. 2
REVISED

Nomination & Declaration Form

(FOR UNEXEMPTED/EXEMPTED ESTABLISHMENT)
Declaration & Nomination Form under the Employee’s
Provident Fund and Employee’s Pension Scheme
(Paragraph 33 and 61 (1) of the Employee’s Provident Fund Scheme, 1995 and
Paragraph 18 of the Employees Pension Scheme 1995)

1. Name (in block letters)..........................................................................................................................................

2. Father’s Name/Husband’s Name.........................................................................................................................
3. Date of Birth.................................... 4. Gender............................ 5. Marital Status.......................................

6. Account No.............................................................................................................................................................

7. Address Permanent................................................................................................................................................
Temporary.............................................................................................................................................................

PART-A (EPF)
I hereby nominate the person(s)/cancell the nomination made by me previously and nominate the person(s) mentioned
below to receive the amount standing to my credit in the Employee’s Provident Fund in the event of my death.
If the nominee is a
minor name &
Name of the Nominee’
s relationship &
Address relationship Date of Birth accumulations in address of the
with the Provident Fund to be guardian who may
member paid to each nominee receive the amount
during the minority
nominee

1 2 3 4 5 6

1.

2. *I certified that I have no family as defined in para (2) (g) of the Employee’s Provident Fund Scheme, 1995 and
should I acquire a family hereafter the above nomination should be deemed as cancelled.
Certified that my father/mother is/are dependent upon me.
Strike out whichever is not applicable.
Signature or thumb impression of the subscriber

4
 PART-B (EPS)
I hereby furnish the particulars of the members of my family who would be eligible to receive Family Pension & Life
Assurance benefits in the event of my premature death.
S. No. Name and Address of the Family Member Age or Date Relationship with
of Birth the Member
Name Address
1 2 3 4 5

Certified that I have no family defined in Part 2 (vii) of the Employee’s Pension Scheme 1995 and should I acquire family
hereafter I shall furnish particulars thereon in the above form.
I hereby nominate the following person for receiving the monthly widow pension (admisible) under Para 162 (i) & (ii) in
the event of my death without leaving any eligible family member for receiving pension.

Name and Address of the Nominee Date of Birth Relation with the Member

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

Certificate by Employer
Certified the the above declaration and nomination has been signed/thumb impression before me by Shri/Smt./
Kum............................................................employed in my establishment after he/she has read the entire/The entires
has been read over to him/her and got confirmed by him/her.
Place.............................. Signature of the employer of other
authorised officer of the establishment

Dated the.................................... Designation

DIL/DFSPL/DASMPL
F-2/7, Okhla Indl. Area, Phase-I, New Delhi-110020

5
 New Form No.-11 - Declaration Form
(To be retained by the employer for future reference)
EMPLOYEES’ PROVIDENT FUND ORGANISATION
Employees’ Provident Fund E Scheme, 1952 (Paragraph 34 & 57) &
Employees’ Pension Scheme, 1995 (Paragraph 24)
(Declaration by a person taking up employment in any establishment on which EPF Scheme, 1952 and /or EPS, 1995 is applicable)

1. Name of the member

2. Father’s Name Spouse’s Name

(Please tick whichever is applicable)

3. Date of Birth: (DD / MM / YYYY )

4 Gender: (Male/Female/Transgender)
5 Marital Status: (Married/Unmarried/Widow/Widower/Divorcee)
6 (a) Email ID:
(b) Mobile No.:

7 Whether earlier a member of Employees’ Provident Fund Scheme, 1952 Yes /No

8 Whether earlier a member of Employees’ Pension Scheme, 1995 Yes / No

Previous employment details: [if Yes to 7 AND/OR 8 above]

a) Universal Account Number:

b) Previous PF Account Number:

c) Date of exit from previous employment: (DD/MM/YYYY)

d) Scheme Certificate No. (if issued)

e) Pension Payment Order (PPO) No. (if issued)

1 a) International Worker: Yes / No

0
b) If yes, state country cf origin (India/Name of other country)

c) Passport No.

d) Validity of passport [(DD/MM/YYYY)to (DD/MM/YYYY)]

1 KYC Details: (attach self attested copies of following KYCs)

1
a) Bank Account: No. & IFS Code

b) AADHAR Number

c) Permanent Account Number (PAN), if available

UNDERTAKING
1) Certified that the particulars are true to the best of my knowledge.
2) I authorize EPFO to use my Aadhar for verification/authentication/eKYC purpose for service delivery.
3) Kindly transfer the funds and service details, if applicable, from the previous PF account as declared above to
the present P.F. Account. (The transfer would be possible only if the identified KYC detail approved by previous
employer has been verified by present employer using his Digital Signature Certificate)
4) In case of changes in above details, the same will be intimated to employer at the earliest.

Date:
Place: Signature of Member
DECLARATION BY PRESENT EMPLOYER
A. The member Mr./Ms./Mrs. .......................................has joined on ..........................and has been allotted PF
Number .....................................................................................................................
B. In case the person was earlier not a member of EPF Scheme, 1952 and EPS, 1995:
• (Post allotment of UAN)The UAN allotted for the member is
• Please Tick the Appropriate Option:
• The KYC details of the above member in the JAN database
• Have not been uploaded
• Have been uploaded but not approved
• Have been uploaded and approved with DSC
C. In case the person was earlier a member of EPF Scheme, 1952 and EPS, 1995:
• The a’Dove PF Account number/UAN of the membe as mentioned in (A) above has been tagged with his/her
UAN/Previous Member ID as declared by member.
• Please Tick the Appropriate Option:-
• The KYC details of the above member in the UAN database have been approved with Digital Signature
,

Certificate and transfer request has been generated on portal.

• As the DSC of establishment are not registered with EPFO, the member has been informed to file
physical claim (Form-a3) for transfer of funds from his previous establishment.
Date:

Signature of Employer with Seal of Establishment

6
 DECLARATION FOR ESIC ENROLLMENT
Are you covered under ESIC, if yes mention ESI no:________________________________

Employee Name: Date of Birth:

Marital Status : Date of Joining :
Name of Father/Husband : Gender:
Present Address with Permanent address with
Pin code No & Mobile No pin code No &Mobile No:
:

Dispensary / IMP:

FAMILY DETAILS :
Name Relationship with Date of Birth Residing Address with
the Employee (DD/MM/YYYY) District and Pin code No

NOMINEE DETAILS

Name of Nominee Relationship with Percentage% Address of Nominee

Employee

DECLARATION FOR MEDICLAIM ENROLLMENT

(To be filled by only employee not covered under ESIC)

Employee Name Date of Birth

Personal Mail ID Aadhaar Card No

Mobile No Emp. Code (if allotted)

Dependents Details:

Name DOB(DD/MM/YYYY) Relationship with employee

Who should be covered (Eligible employees + spouse + 2 children) Self + spouse + child + childM-5 & above level,
joining can include their parents in Mediclaim. However, the No. of dependents cannot exceed