EMPLOYEE DATA FORM

I give my consent to group companies of Adani Group or its affiliate enes located in India to process (which
includes in parcular collecng, recording, storing, ulizing, processing, sharing or transferring) any Personal
Idenfiable Informaon (defined as informaon associated with my name or personal identy including my date
of birth, address/e-mail address, telephone number, unique government issued number, passport details, Aadhar
number, driving license number, etc.) and any Sensive Personal Data or Informaon (namely password, financial
informaon such as bank account, physical, physiological and mental health condion, sexual orientaon, medical
records and history, biometric informaon) which may be in the possession of Adani Group or obtained in future.
Such informaon shall be processed by Adani Group strictly on a need-to-know basis and retained ll required for
business purposes including statutory requirements pertaining to compensaon and benefits.

I acknowledge and agree that such informaon may be transferred, on a business need-to-know basis or
employment-related maer, to Adani Group's subsidiary/affiliated companies, business partners, external
consultants, vendors, regulatory or administrave agencies, and its customers (where specifically requested) with
obligaons to maintain a similar level of protecon.

As part of my onboarding journey, Adani Group will be sharing with me some informaon about Adani Group and
its processes, policies including personal informaon of the candidate / officers. I am requested and advised not
to share this informaon with any third party or further circulate or distribute it (including uploading it on social
media sites).

I will have full rights to access and review my data, update it, and the right to withdraw this consent if necessary.

My records and informaon will be kept secure and handled strictly in accordance with the Adani Group Data
Classificaon Guidelines and Data Privacy Policy.

I acknowledge and consent that in conjuncon with my applicaon for employment, Adani Group will use the
services of the outside vendors to research and verify the informaon that I have provided

USER DETAILS:

Name Mr. Subhash Kailash Yadav

Date of birth 14 March 1983
Gender Male
E-mail subhashkailashyadav1221@gmail.com
Mobile number +91-9767400475
Alternate number +91-9764784995
Naonality India
Religion Hinduism
Blood group B +ve
Marital status Married
Date of Marriage 15 May 1995
Domicile state Uar Pradesh
Country of birth India
Community/Category OBC
Mother tongue Hindi
Are you differently abled? No
Please specify

IDENTIFICATION DETAILS:

Idenficaon mark Mole on le hand elbow and Right hand wrist
Permanent account number AGSPY0125G
Aadhaar number 289234369417
Passport number N

LANGUAGES KNOWN

Languages known Speak Read Write

Hindi, English and Marathi yes yes yes

PERMANENT ADDRESS:

Complete Permanent Address State & Country Start date

Sai Jeevdani Appartment,
R.no-202, Phoolpada Road ,
Apposite Ramchandra gate
MAHARASHTRA, IN 12 April 2015
no.2 Near, water filter , Virar
(East) Virar Next to Marathi
school Mumbai401305

ADDRESS HISTORY:

Present/Past
Complete Address State & Country Start date End date
Address
Sai Jeevdani
Appartment,
R.no-202, Phoolpada
Road , Apposite
Yes Ramchandra gate MAHARASHTRA, IN 12 April 2015
no.2 Near, water
filter , Virar (East)
Virar Next to Marathi
school Virar 401305

FAMILY DETAILS:

Date
Relaonship Title Full name of Address Contact number Gender
birth
 Parui, Kathal,
Gunj,
Gosainpur
Mohav,
Soni Subhash 01 July Gosaipur,
Spouse Mrs. +91-9764784995 Female
Yadav 1989 Varanasi,
Uar
Pradesh, pin
Code-221100
1

EMERGENCY CONTACT (This informaon will be used by Adani in case of emergencies):

Title Name Relaonship Contact

Soni
MRS. Spouse +91-9764784995
Yadav

EDUCATION DETAILS:

Is this your highest qualificaon? Qualificaon: Discipline/Major:

Yes Bachelor of Arts - B.A. Yes
School/College/Instuion: Board/University:
Start date:
Dr Ram Manohar Lohiya PG college Veer Bahadur Purvanchal University
29 August 2003
ghazipur (VBS Purvanchal University)
End date: Year acquired: Mode of educaon:
10 July 2005 2005 Full Time
School/College/University address:
Enrollment/Roll/Registraon:
Dr. Ram Manohar Lohiya PG College
PU02/31010
Jhotari, Dhamupur Ghazipur (UP)

CONSENT & DECLARATION DETAILS:

Are you a fresher No

Do you consent for reaching out to previous
yes
HR/supervisor for verificaon?

WORK EXPERIENCE DETAILS:

Employer name: Currently working here? Start date:

TCL No 01 October 2008
End date: Reason for leaving Address:
01 November 2009 Career Growth BKC
City: State: Country:
Mumbai Maharashtra India
Employee ID:
Zipcode: Company contact number:
635492
Designaon: Salary:
Name of reporng manager:
Security officer 17000
 Contact number : Work email of reporng manager: Name of HR point of contact:
Work email of HR point of contact:
Contact Number:
sudha@nisaeye.com

Employer name: Currently working here? Start date:

NISA No 01 January 2007
End date: Reason for leaving Address:
01 September 2008 career growth Khar Road
City: State: Country:
Mumbai Maharashtra India
Employee ID:
Zipcode: Company contact number:
635492
Designaon: Salary:
Name of reporng manager:
Security Officer 17000
Contact number : Work email of reporng manager: Name of HR point of contact:
Work email of HR point of contact:
Contact Number:
sudha@nisaeye.com

Employer name: Currently working here? Start date:

PVR INOX LTD Yes 06 December 2016
Address:
2nd Floor, Inorbit Mall, Malad
End date: Reason for leaving
West, New Link Road. Malad -
400064
City: State: Country:
Mumbai Maharashtra India
Zipcode: Company contact number: Employee ID:
400064 +91-9167135718 4562
Designaon: Salary: Name of reporng manager:
AM - Security Manager 517000 Ravindra More
Contact number : Work email of reporng manager: Name of HR point of contact:
+91-9167135718 ravindra.more@inoxmovies.com Sushant Patkar
Contact Number: Work email of HR point of contact:
+91-7506377179 ravindra.more@inoxmovies.com

PROFESSIONAL REFERENCE:

Name Contact Designaon Employer Email

Ravindra More +91-9167135718 General Manager PVR INOX ravindra.more@inoxmovies.com

EMPLOYEE PROVIDENT FUND AND PENSION SCHEME DETAILS:

Employee Provident Fund Scheme (Part of form 11 declaraon):

Are you a member of emloyee provident fund
Yes
scheme,1952?
Are you a member of employee pension fund
Yes
scheme,1995?

Previous Employment Details (Only applicable if part of pension fund 1952):

Establishment name & address (last organizaon
PVR INOX Ltd.
where-in PF was applicable)
Universal account number 100443699553
PF account number(last issued) DLCPM00200290000106643
Date of joining (of last organsiaon where PF was
06 December 2016
applicable)
Date of exit (from last organizaon where PF was
applicable)

Previous Employment Details (Only Applicable if part of pension fund 1995) :

Name and address of the trust PVR INOX Ltd
Universal account number 100443699553
Member EPS account number DLCPM00200290000106643
Date of joining 06 December 2016
Date of exit
Non contributory period (NCP Days)

Internaonal Worker Declaraon(part of PF declaraon form 11):

Do you have OCI/VISA?
State the country of origin(India/name of other
country)
OCI/VISA number
OCI/VISA valid from
OCI/VISA valid to
OCI/VISA Date of issue
Bank details:
Bank name Axis Bank
Bank account number 916010080492987
IFSC UTIB0000465
Branch name Lamington road Mumbai
Account holder's name Subhash Chandra Yadav

NOMINEE DETAILS:

NOMINATION(S) FOR GRATUITY

Name of the nominee Relaonship Date of birth Percentage
Soni Subhash Yadav Spouse 01 July 1989 100

Nominaon(s) for Provident Fund (Form 2): I hereby nominate the person(s)/cancel the nominaon made by
previously and nominate the person(s), menoned below to receive the amount standing to my credit in the
employees provident fund, in the event of my death *
Total amount or share of
Name & address of the accumulaon in Provident
Relaonship Date of birth
nominee Fund to be paid to the
nominee
Soni Subhash Yadav
Parui, Kathal, Gunj,
Gosainpur Mohav, Spouse 01 July 1989 100
Gosaipur, Varanasi, Uar
Pradesh, pin Code-2211001

Nominaon(s) for Provident Fund (Form 2): I hereby furnish below parculars of the members of my family
who would be eligible to receive widow/widower/children pension in event of my death (You can only
nominate your spouse and/or children below the age of 25 in this secon)"
Total amount or share of
Name & address of the accumulaon in Provident
Relaonship Date of birth
nominee Fund to be paid to the
nominee

Nominaon(s) for Provident Fund (Form 2): I hereby nominate the following person for receving the monthly
pension (admissible under para 16 (2) (A) (1) & (11)the event of my death without leaving any eligible family
member for receiving pension (You can only nominate your dependent parents in this secon)
Total amount or share of
Name & address of the accumulaon in Provident
Relaonship Date of birth
nominee Fund to be paid to the
nominee

EMPLOYEES STATE INSURANCE CORPORATION (ESIC)

Were you an ESIC member earlier? No
Previous Insurance Number
Name & address of employer
Nominaon