I have Attached Muster Roll Cum Wages Register
(FOR UNEXEMPTED ESTABLISHMENTS ONLY)
THE EMPLOYEES’ PROVIDENT FUND SCHEME, 1952
THE EMPLOYEES’ FAMILY PENSION SCHEME 1971
Declaration by a person taking up employment in an establishment in which the Employees Provident Fund and Family Pension Fund Scheme are in Force.
I, ____________________________________son/wife/daughter of Shri / Smt. _________________________ do hereby solemnly declare that
(a) I was last employed in M/s _________________________________________________________
(Name & full address of the establishment)
and left services on _______________________________________(Prior to that I was employed with
M/s____________________________________ from _______________to ______________
(b) I was a member of _____________________________________________Provident Fund and also of the family pension fund from ________________________to ___________________and my account number(s) was / were ___________________________________________________
(c) I have / have not withdrawn the amount of my Provident Family Pension Scheme.
(d) I have / have not drawn superannuation benefits in respect of my past services from an employer.
(e) I have never been a member of any Provident fund and / or Family Pension Scheme.
Date ___________________________ Signature or right / left hand thumb impression of the employee.
(To be filled in by the employer only when the person employed had not already been a member of the Employees’ Provident Fund)
Shri_______________________________________ is appointed as _______________________________
(Name of the employee) (Designation)
(Name of the Factory / establishment)
with effect from ______________________________.
(Date of Appointment)
Date_________________________ Signature of the employer or Manager or other authorized Officer
N.B.: The Principal employer should have filled it up also n respect of employees to be employed by through a contractor.