Last Name First Name
PAN, DOB,
Gender & Blood
Group
Mandatory
Emergency
person Name &
Mobile No &
Number
Email id
Family Details
Mandatory
Mandatory
Sign Previous
Organisation any
HR/Manager
reference
1. Name as per
6&7. Email id,
your Aadhar
Mobile No & DOJ
Card
2. Father’s name
as per your PAN
9&10. If you had Card
PF in your 3,4&5. DOB,
previous Gender & Marital
organization then Status
tick on YES
1.Your Name as per
Bank Account
2. Acc No
11. Previous 3. IFSC Code
Establishment
Name, UAN&PF 8.Your Name as per
No(check PAN
payslip), DOJ & PAN NO
Exit Date Your Name as per
Aadhar Aadhar No
13. Tick on NO
14. If you have
withdrawn your
PF in your then
tick on YES
Sign
1. Name as per
3,4&5. Mandatory
your Aadhar Card
2. Father’s name
as per your PAN
Card 6. Keep it blank
8. Mandatory
7. Mandatory
As per your wish If you mention
1 or 2 nominee 1 Nomiee then
you can mention write 100%
2 Nominees then
50%-50%
Address, Nominee
relation,
DOB/Approx. Age
Sign
-Mandatory
Employee who is
married has to
fill this table and
below table has to
be kept blank. Employee who is
single has to fill
Names you this table and
mention on the below table has to
first page of this be kept blank.
form has to be
same here Names you
mention on the
first page of this
form has to be
same here
Sign
Mandatory
Mandatory
Mandatory
4. Disability
Status would be
NO
5. Marital Status -
Address, Mobile Single/Married/
No and Email id Divorce
Mandatory
As per your wish 1
or 2 nominee you
can mention,
Relation &
Address
Mention all
family members
name, DOB,
Relationship
and Aadhar
Number.
Incase if you do
not have Aadhar
No. of any
family member
then you do not
have to mention
their name
