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Employee Code : ...... .... .. ... .......... .... ..
;,..
Form-11
~ (To br reta ined by the amp/ayer for future reference/
lt~PLOYEES' PROVIDENT FUND ORGANISATION
~ "" fm p!-0.~~s• Provldel'!llllund~ Scheme, 1952(Paragraph 34 & 57) and
Employe~,,.~•en.~l'.> n Scheme, 1955 (Paragraph 24)
(Declarat,on by a p erson taking up employment In any establishment on which EPF scheme, 1952 and/or EPS, 1995 Is applicable )
Nam~ the member (Aadhaar Name) {) US. H'ff\~1 \) Pf\ 0 \.\ '< A'< FIii the employee name oJ pt, Aadhaar
2.
Pita FIii Father Name/Husband Name
Date
Fifi Date of Birth as Der Aadhoor
Gend
Fill Gender
Marl
D FIii Marital Status
(al Email ID: VPl1 Fifi Email Id & Mab/le Number Registered with
b) Mobile No (Aadhaa
Aadhaar
Whether earlier a member of Employees 'provident f ynd Scheme, 1952? Yes / No
Whether earlier a member of Emplovees' flenslon Scheme~95?
Yes / No
Previous employment details {If Yes, 7 & 8 details above)
Fifi Previous UAN If any, Else leave blank
_ _a_) _ Universal Account Number (UAN) I !'.)_ I b o
b) Previous PF Account Number FIii Previous PF Number if any. Else leave blonk
Date of exit from previous E FIii Previous DOL If any. Else leave bla_fl!
Scheme Certificate No (If Issued Leave Blank
ej Pension Payment Order (PPO) (If Issued} Leave Blank
a) International Worker:
N~ Foreign employee Yes I No
10 bl If yes, state country of origin (Name of other country) If Foreign employee, update. Else leave Blank
~ If Foreign employee, update. Else leave Blank
d)
If Foreign employee, updatt. Else leave Blank
11 ·:J I Fill Bonk Account number and IFSC Code
FIii Aodhaor Number
FIi/PAN
First EPF Member Are you EPF After Sep 2014 earned EPS
First Employment If Yes, EPF Amount If Yes, EPS (Pension)
Enrolled Date Member (Pension) Amount Withdrawn
EPFWages Withdrawn? Amount Withdrawn?
before 01/09/2014 before Join current Emplover?
12 If Previously If Previously Whether Previous
employed, fill first employed, fill first Whether Previous Whether Previous Pension
~/No PF Contributions Pens/on
DOJ. Else leave PF Wage, Else Contrlbutlons7adrawn
withdrown"Yes/No Contrlbutlon~W
bionic leave blank withdrawn Yes/,
Yes/, a
UNDERTAKING
1) Certified that the particulars are true to the best of my Knowledge,
2) t authorize EPFO to use my Aadhar for verlflcatlon/authentlcatlon/e-KVC 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 PF account. (The transfer would
be possible only if the Identified KYC details approved by previous employer has been verified by present employer
uslng ¥1s Dlaltal Sl1nature)
4) In case of changes In above details, the same will be Intimated to employer at the earliest.
Date : i r ..I O( .\- ),o2,~
Place: C, 0 RU tj ~ f\ I"" Sl1nature of Member
Employte to sign here
DECLARATION BY P,RESENT EMPLOYER
A. The member Mr/Ms/Mrs ... Employee Name ... has Joined on ... DOJ... and has been allotted PF No . ... New 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 or the member Is)
Please Tick the Appropriate Option: The KYC details of the above member In the UAN database
Have not been uploaded Have been uploaded but not approved Have been uploaded ind approved with~
C. tn case the person w.is earlier a member of EPF scheme, 1952 and EPS, 1995:
https://neptuneprc.com
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