Documents Check List of New Joining

Status
S No. Documents Yes No Remarks

1 Resume/CV

2 Joining Forms

3 ESI-TIC

4 Form-2

5 Form-11
6 Police Verification
7 Bank Account Details
PAN Card
Passport
Voter ID
8 ID Proof/Address Proof
Aadhar Card
Ration Card
Other (If any)
High School Certificate
Intermediate Certificate
Graduation Certificate
9 Educational Certificates
Post-Graduation Certificate
Diploma (ITI/Polytechnic) Certificate
Other (If any)
10 Copy of Resignation Letter
11 Last Month Salary Slip
12 Experience Certificate

Employee Code:- ____________________________________________

Employee Name:- ___________________________________________

Location:- __________________________________________________

Candidates' Signature:- ______________________________________

Page 1 of 6
Spectrum Talent Management
Affix
C-142, Sector- 63, Noida, (U-P), PIN: 201307
Recent

Photograph
Joining Form

1. Personal Details

First Name: __________________Middle Name: ________________Last Name: __________________

Fathers’ Name : ______________________________________________________

Mothers’ Name : ______________________________________________________

Blood Group : ______________________________________________________

Date of Birth : _____________________ Place of Birth: _____________________

Marital Status : _____________________ Date of Marriage: __________________

Spouse Name : ______________________________________________________

Nominee : _________________________________Relationship: __________

Gender (Male/Female) : _____________ Total Experience: _______Years_______Months

Permanent Address : ______________________________________________________

____________________________________________________PIN Code: ____________

Correspondence Address : ___________________________________________________

____________________________________________________PIN Code: ____________

Personal Email ID & Contact No.: ______________________________________________

Emergency Contact Person : _________________________________________________

Emergency Contact No. : __________________________Relationship: _____________

Identification Mark : ___________________________________________________

Physical disability (if any) : ___________________________________________________

Page 2 of 6
Language Proficiency

Read : ___________________________________________________________________

Write : ___________________________________________________________________

Speak : ___________________________________________________________________

Understand : ___________________________________________________________________

PAN Card/Passport Details: (Please attach copies)

Document Document No Place of Issue Date of Issue Date of Expiry

PAN Card

Passport

Driving License

Family Particulars
S. Monthly
Name of the Dependent Date of Birth Relationship Occupation
No. Earning
1

Page 3 of 6
Educational Qualification Details (starting from Highest/Latest Degree)
S. Passing Marks
Class/Course/Degree Board/University Percentage
No. Year Obtained
1

2. Employment Details

Please list your employment / experience in chronological order, with the most recent first and include

unpaid or voluntary work, if relevant

Work Experience (With the most recent first)

S. Salary Reason for
Organization Designation Start Date End Date
No. (CTC) Leaving
1

Page 4 of 6
3. Criminal Convictions

Have you ever been convicted of a criminal offence? Yes ( ) No ( )

If yes, please give details of offence, date of conviction and sentence imposed below and continue on
separate sheet if necessary.

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

4. References

Please give the name and address of two people ( not relatives ), one of whom should be preferably your
present or most recent employer.

Name : Name :

Position Position:

Address: Address:

Telephone No: Telephone No:

Page 5 of 6
5. Declaration

I Declare that to the best of my knowledge the information given in support of my application is true and
complete. I understand that any misrepresentation or omission here in above renders me liable for
termination / dismissal from service without notice.

Date : Place : Signature :

For Office Use Only- Human Resource Department

Employee Code : ________________________________________________

Date of Joining : ________________________________________________

Designation : ________________________________________________

Department : ________________________________________________

Location of Posting : ________________________________________________

Reporting Manager : ________________________________________________

Email ID Official : ________________________________________________

Contact No Official : ________________________________________________

Name of the HR Person Signature

PS: Email ID should be “first name.Last name/initials@spectrumtalentmanagement.com”

Page 6 of 6
 Declaration Form
(To be retained by the Employer for future reference)

Employees’ Provident Fund Organization

THE EMPLOYEES’ PROVIDENT FUNDS SCHEME, 1952 (PARAGRAPH-34 & 57)
&
THE EMPLOYEES’ PENSION SCHEME, 1995 (PARAGRAPH-24)

DECLARATION BY A PERSON TAKING UP EMPLOYMENT IN AN ESTABLISHMENT ON WHICH EMPLOYEES’ PROVIDENT FUND SCHEME,
1952 AND/OR EMPLOYEES’ PENSION SCHEME, 1995 IS APPLICABLE.
(PLEASE GO THROUGH THE INSTRUCTIONS)

1) NAME (TITLE)
MR . MS. MRS.
(PLEASE TICK)

2) DATE OF BIRTH D D M M Y Y Y Y

3) FATHER’S/ MR .
HUSBAND’S NAME

4) RELATIONSHIP IN RESPECT OF (3) ABOVE FATHER HUSBAND

(PLEASE TICK)

5) GENDER MALE FEMALE TRANSGENDER

(PLEASE TICK)

6) MOBILE NUMBER
(IF ANY)

7) EMAIL ID (IF ANY)

8) WHETHER EARLIER A MEMBER OF THE EMPLOYEES’ PROVIDENT FUND SCHEME, 1952 ?

(PLEASE TICK) YES NO
9) WHETHER EARLIER A MEMBER OF THE EMPLOYEES’ PENSION SCHEME, 1995?
(PLEASE TICK) YES NO
IF RESPONSE TO ANY OR BOTH OF (8) & (9) ABOVE IS YES, THEN MANDATORILY FILL UP THE PREVIOUS EMPLOYMENT DETAILS
AT (10,11&12):
Page 1 of 3
 A. PREVIOUS EMPLOYMENT DETAILS
10)THE DETAILS OF THE UNIVERSAL ACCOUNT NUMBER (UAN) OR PREVIOUS PF MEMBER ID:

UAN
OR
PREVIOUS PF MEMBER ID REGION CODE OFFICE CODE ESTABLISHMENT ID EXTENSION ACCOUNT NUMBER

11) DATE OF EXIT FOR PREVIOUS D D M M Y Y Y Y

MEMBER ID (DD/MM/YYYY)

12) (A) IF SCHEME CERTIFICATE ISSUED FOR PREVIOUS EMPLOYMENT, THEN SCHEME CERTIFICATE NUMBER:___________
(B) IF PENSION PAYMENT ORDER (PPO) ISSUED FOR PREVIOUS EMPLOYMENT, THEN PPO NUMBER:______________

B. OTHER DETAILS

13) INTERNATIONAL WORKER YES NO

(PLEASE TICK)

IF THE REPLY TO (13) ABOVE IS YES, THEN ENTER THE DETAILS IN 13(A), 13(B) & 13(C):
13(A) COUNTRY OF ORIGIN (Please Tick)
INDIA OTHER THAN INDIA (IF YES, PLEASE
MENTION NAME OF THE COUNTRY)

13(B) PASSPORT NUMBER ______________________________

13(C) PASSPORT VALID FROM

D D M M Y Y Y Y

To D D M M Y Y Y Y

14) EDUCATIONAL ILLITERATE

NON-
MATRIC
SENIOR
GRADUATE
POST
DOCTOR
TECHNICAL/
QUALIFICATION MATRIC SECONDARY GRADUATE PROFESSIONAL
(PLEASE TICK)

15) MARITAL STATUS MARRIED UNMARRIED WIDOW/ WIDOWER DIVORCEE

(PLEASE TICK)

16) SPECIALLY ABLED YES NO IF YES, TICK THE CATEGORY

(PLEASE TICK) LOCOMOTIVE VISUAL HEARING

Page 2 of 3
17) KYC DETAILS KYC DOCUMENT TYPE NAME AS ON KYC DOCUMENT NUMBER REMARKS, IF ANY
BANK ACCOUNT-1* IFSC CODE*
NPR/AADHAAR
PERMANENT ACCOUNT
NUMBER (PAN)
PASSPORT EXPIRY DATE
DRIVING LICENCE EXPIRY DATE
ELECTION CARD
RATION CARD
ESIC CARD
* Mandatory Field (NOTE: BANK ACCOUNT NUMBER (ALONG WITH IFSC CODE) IS MANDATORY. YOU
ARE HOWEVER ADVISED TO PROVIDE ALL KYC DOCUMENTS AVAILABLE WITH YOU IN ADDITION TO MANDATORY KYCS TO
AVAIL BETTER SERVICES. SELF-ATTESTED PHOTOCOPIES OF THE DOCUMENTS MUST BE ATTACHED WITH THIS FORM.

C. UNDERTAKING:
A. I CERTIFY THAT ALL THE INFORMATION GIVEN ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE AND BELIEF.
B. IN CASE, EARLIER A MEMBER OF EPF SCHEME, 1952 AND/OR EPS, 1995,
(I) I HAVE ENSURED THE CORRECTNESS OF MY UAN/ PREVIOUS PF MEMBER ID.
(II) THIS MAY ALSO BE TREATED AS MY REQUEST FOR TRANSFER OF FUNDS AND SERVICE DETAILS IF APPLICABLE FROM
THE PREVIOUS ACCOUNT AS DECLARED ABOVE TO THE PRESENT P.F. ACCOUNT. (THE TRANSFER WOULD BE POSSIBLE
ONLY IF THE IDENTIFIED KYC DETAILS APPROVED BY PREVIOUS EMPLOYER HAS BEEN VERIFIED BY PRESENT
EMPLOYER USING HIS DIGITAL SIGNATURE CERTIFICATE).
(III) I AM AWARE THAT I CAN SUBMIT MY NOMINATION FORM THROUGH UAN BASED MEMBER PORTAL.

DATE:
PLACE: SIGNATURE OF MEMBER
DECLARATION BY PRESENT EMPLOYER
A. THE MEMBER Mr./Ms./Mrs. ………………………….. HAS JOINED ON ………………….. AND HAS BEEN ALLOTTED PF MEMBER ID
…………………………………………...
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 UAN 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 ABOVE MEMBER ID OF THE MEMBER 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-13) FOR TRANSFER OF FUNDS FROM HIS PREVIOUS ESTABLISHMENT.

DATE: SIGNATURE OF EMPLOYER WITH SEAL OF ESTABLISHMENT

Page 3 of 3
 (FORM 2 REVISED)

NOMINATION AND DECLARATION FORM FOR UNEXEMPTED/EXEMPTED ESTABLISHMENTS

Declaration and Nomination Form under the Employees Provident Funds and Employees Pension Schemes
(Paragraph 33 and 61 (1) of the Employees Provident Fund Scheme 1952 and Paragraph 18 of the Employees
Pension Scheme 1995)

1. Name (IN BLOCK LETTERS) : _______________________________________________________________________________

Name Father’s / Husband’s Name Surname

2. Date of Birth : ___________________ 3. Account No. ___________________

4. *Sex : MALE/FEMALE: ______________________ 5. Marital Status ________________________________________

6. Address Permanent / Temporary : _____________________________________________________________________________

________________________________________________________________________________

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

1 2 3 4 5 6

1 *Certified that I have no family as defined in para 2 (g) of the Employees Provident Fund Scheme 1952 and should I
acquire a family hereafter the above nomination should be deemed as cancelled.

2. * Certified that my father/mother is/are dependent upon me.

Strike out whichever is not applicable Signature/or thumb impression

of the subscriber

PART – (EPS)
Para 18
I hereby furnish below particulars of the members of my family who would be eligible to receive Widow/Children Pension in the
event of my premature death in service.

Sr. No Name & Address of the Family Member Age Relationship with the member

(1) (2) (3) (4)

Certified that I have no family as defined in para 2 (vii) of the Employees’s Family Pension Scheme 1995 and should I acquire a
family hereafter I shall furnish Particulars there on in the above form.

I hereby nominate the following person for receiving the monthly widow pension (admissible under para 16 2 (a) (i) & (ii) in the
event of my death without leaving any eligible family member for receiving pension.

Name and Address of Date of Birth Relationship with member

the nominee

Date ___________________

Signature or thumb impression

of the subscriber

____________________________________________________________________________________________________________

CERTIFICATE BY EMPLOYER

Certified that the above declaration and nomination has been signed / thumb impressed before me by Shri / Smt./
Miss_________________________________________________________________ employed in my establishment after he/she has
read the entries / the entries have been read over to him/her by me and got confirmed by him/her.

Date : _____________________ Signature of the employer or other authorised officer of the

establishment

Place :
Name & address of the Factory /Establishment
Date :
 ?kks"k.kk i=k DECLARATION FORM QkeZ&1@Form-1
?kks"k.kk i=k deZpkjh }kjk Hkjk tk,xkA QkeZ ds LkkFk iksLVdkMZ vkdkj ds nks QksVksxzkQ Hkh yxk, tkus pkfg,A QkeZ Hkjus ls igys
ihB i`"B ij nh xbZ fgnk;rksa dks Hkyh&Hkkafr i<+ ysuk pkfg,A ;g QkeZ fu%'kqYd gSA
To be filled by employee after reading instruction overleaf. Two Postcard Size phtographs to be attached with the
form. This form is free of cost.
¼d½ chekÑr O;fDr ds fooj.k ¼[k½ fu;kstd ds fooj.k
(A) INSURED PERSON'S PARTICULARS (B) EMPLOYER'S PARTICULARS

1- chek la[;k@Insurance No. 9- fu;kstd dh dwV la[;k

Employer's Code No.
2- uke ¼Li"V v{kjks esa½
Name in block letters
10- fu;qfDr dh rkjh[k fnu eghuk o"kZ
Date of Appointment Day Month Year
3- firk@ifr dk uke
Father's/Husband's Name 11- fu;kstd dk uke vkSj irk@Name & Address of the Employer
4- tUe dh frfFk fnu eghuk o"kZ 5- oSokfgd fookfgr@ __________________________________________________
Date of Birth Day Month Year izkfLFkfr vfookfgr __________________________________________________
Marital fo/kok __________________________________________________
Status M/U/W 12- ;fn igys fu;kstu esa jgs gSa rks Ñi;k fuEufyf[kr C;kSjs nhft,
6-fyax@Sex iq-e-/M.F. In case of any previous employment please fill up the details as under.

7- orZeku irk@Present Address 8- LFkk;h irk@Permanent Address ¼d½ fiNyh chek la[;k
______________________ ______________________ (a) Previous Ins. No.
______________________ ______________________ ¼[k½ fu;kstd dwV la[;k
______________________ ______________________ (b) Employer's Code No.
fiu dksM fiu dksM
Pin Code Pin Code ¼x½ fu;kstd dk uke o irk
VsyhQksu uEcj@bZ&esy irk@ VsyhQksu uEcj@bZ&esy irk@ (c) Name & Address of the Employer

'kk[kk dk;kZy; vkS"k/kky;

Brach Office Dispensary
VsyhQksu uEcj@bZ&esy irk@e-mail address
¼d½ e`R;q dh fLFkfr esa udn fgrykHk ds Hkqxrku ds fy, d-jk-ch- vf/kfu;e] 1948 dh /kkjk 71@d-jk-ch- ¼dsUnzh;½ fu;e] 1950 ds fu;e 56¼2½ ds varxZr ukfer ds C;kSjsA
(c) Details of Nominee u/s 71 of ESI Act 1948/Rule-56(2) of ESI (Central) Rules, 1950 for payment of cash benefit in the event of death.

uke@Name ukrsnkjh@Relationship irk@Address

eSa ,rn~}kjk ?kks"k.kk djrk@djrh gwa fd esjs }kjk izLrqr fd, x, fooj.k esjh tkudkjh vkSj fo'okl ds vuqlkj lgh gSA eSa vius ifjokj ds lnL;ksa esa gq, ifjorZu dh lwpuk
15 fnu ds Hkhrj izLrqr djus dk opu Hkh nsrk gwa@nsrh gwaA
I hereby decalare that the particulars given by me are correct to the best of my knowledge and belief. I undertake to intimate the corporation any
changes in the membership of my family within 15 days of such change.

fu;kstd ds izfrgLrk{kj chekÑr O;fDr ds gLrk{kj@vaxwBk fu'kku

Counter signature by the employer Signature /T.I.of IP.

lhy lfgr gLrk{kj

Signature with seal
¼?k½ chekÑr O;fDr ds ifjtuksa dk fooj.k
(D) Family Particulars of Insured person
Ø-la- uke QkeZ Hkjus dh rkjh[k deZpkjh ds lkFk ukrsnkjh D;k muds lkFk jg ;fn ugha rks vkokl
SI. No. Name dks vk;q@tUe&rkjh[k Relationship with the jgs gSa\ crk,a dk LFkku n'kkZ,a
Date of Birth/Age as on Employee Whether residing If' No' state Place of
date of filling form with him/her. Residence
gk¡@Yes ugha@No dLck@Town jkT;@State

d-jk-ch- fuxe vLFkk;h igpku i=k ¼fu;qfDr dh rkjh[k ls 3 eghus rd oS/k½

ESI Corporation Temporary Identity Card (Valid for 3 month from the date of appointment)
uke@Name
chek la[;k@Ins. No. fu;qfDr dh rkjh[k@Date of appointment
'kk[kk dk;kZy; vkS"k/kky; QksVks ds fy, LFkku
Branch Office Dispensary (Space for photograph)

fu;kstd dh dwV la[;k o irk

Employer's Code No. & Address

oS/krk
Validity
rkjh[k chekÑr O;fDr ds gLrk{kj@vaxwBs dk fu'kku lhy lfgr 'kk[kk izca/kd ds gLrk{kj
Dated Signature/T.I. of I.P. Signature of B.M. with seal
 vuq n s ' k
INSTRUCTIONS

1- QkeZ&1 dk izs"k.k d-jk-ch- ¼lk/kkj.k½ fofu;e] 1950 ds fofu;e 11 o 12 ds varxZr fofu;fer fd;k tkrk gSA
Submission of Form-I is governed by regulation 11 & 12 of ESI (General) Regulations, 1950

2- ßdqVqEcÞ ls fdlh chekÑr O;fDr ds fuEufyf[kr lHkh vFkok dksbZ ukrsnkj vfHkizsr gS%&
vFkkZr~%& ¼1½ fookfgrh ¼2½ chekÑr O;fDr ij vkfJr dksbZ /keZt ;k nÙkd vo;Ld vkfJr ckyd] ¼3½ dksbZ ckyd tks chekÑr O;fDr
ds miktZuksa ij iw.kZr% vkfJr gS rFkk tks ¼d½ f'k{kk izkIr dj jgk gS] muds 21 o"Z dh vk;q izkIr dj ysus rd ¼[k½ dksbZ vfookfgr iq=kh]
¼4½ dksbZ ckyd tks fdlh 'kkjhfjd vFkok ekufld vilkekU;rk ;k pksV ds dkj.k f'kfFkykax gS rFkk f'kfFkykaxrk jgus rd chekÑr O;fDr
ds miktZuksa ij iw.kZr% vkfJr gS] ¼5½ vkfJr ekrk&firk] ¼C;ksjs gsrq d-jk-ch- vf/kfu;e] 1948 dh /kkjk 2 ds [kaM 11 dks ns[ksa½A
“Family” means all or any of the following relatives of an Insured Person namely:-

(i) a spouse (ii) a minor legitimate or adopted child dependant upon the I.P.; (iii) a child who is wholly dependant on the
earnings of the I.P. and who is (a) receiving education, till he or she attains the age of 21 years (b) an unmarried daughter;
(iv) a child who is infirm by reason of any physcial or mental abnormality or injury and is wholly dependant on the earnings
of the I.P. so long as the infirmity continues; (v) dependant parents (Please see Section 2 clause 11 of the ESI Act 1948 for
details.

3 igpku&i=k vgLrkUrj.kh; gSA

Identity Card is Non-Transferable.

4- igpku&i=k ds xqe gksus dh fLFkfr esa fu;kstd@'kk[kk izca/kd dks rRdky lwfpr fd;k tk,A
Loss of Identity Card be reported to Employer/Branch Manager immediately.

5- fdlh izdkj dh xyr lwpuk nsus dh fLFkfr esa d-jk-ch- vf/kfu;e] 1948 dh /kkjk&84 ds rgr dkuwuh dk;Zokgh dh tk ldrh gSA
Submission of false information attracts penal action Under Section 84 of ESI Act. 1948.

6- ubZ fu;qfDr dh fLFkfr esa Hkyh&Hkkafr Hkjk gqvk ;g QkeZ fu;qfDr ds nl fnu ds Hkhrj lacaf/kr 'kk[kk dk;kZy; esa vo'; gh izLrqr fd;k
tkuk pkfg,A foyEc dh fLFkfr esa fu;kstd ds fo#) /kkjk&85 ds rgr dkuwuh dk;Zokgh dh tk ldrh gSA
This form duly filled in must reach the concerned Branch Office within 10 days of appointment of an Employee. Delay
attracts penal action under Section 85 of the Act, against employer.

7- chekÑr O;fDr gksus ds ukrs vki o vkids ifjokj ds vkfJrtu fpfdRlk fgrykHk izkIr dj ldsaxsA vU; udn fgrykHk gSa] ¼1½ chekjh
fgrykHk ¼2½ vLFkk;h viaxrk fgrykHk ¼3½ LFkk;h viaxrk fgrykHk ¼4½ vkfJrtu fgrykHk ¼5½ izlwfr fgrykHk ¼efgyk deZpkjh ds fy,½A
As an insured person you and your dependant family membes are entitled to full medical care. The other benefits in cash
include (1) Sickness Benefit (2) Temporary Disablement benefit (3) Permanent disablement Benefit (4) Dependants benefit
and (5) Maternity Benefit (in case of woman employees) subject of fulfillment of contributory cnditions.

8- vf/kd tkudkjh ds fy;s Ñi;k fuxe ds osclkbV dks nsa[ksa ;k 'kk[kk dk;kZy; ;k {ks=kh; dk;kZy; ls laidZ djsaA
For more details please contact website of ESIC at www. esic.org. in. or contact Regional Office or Branch Office.

dsoy 'kk[kk dk;kZy; esa iz;ksx gsrq

For Branch Office Use only

1- chek la[;k vkoaVu dh rkjh[k %

Date of allotment of Ins. No. :_________________________________________

2- vLFkk;h igpku i=k tkjh djus dh rkjh[k %

Date of Issue of T.I.C. :______________________________________________

3- vkS"k/kky; dk uke@la[;k %
Name /No. of Dispensary : ___________________________________________

4- D;k vU;ksU; fpfdRlk O;oLFkk miyC/k gS\ ;fn gkaa] rks mYys[k djsa %
Whether reciprocal Medical arrangements involved. if yes, please indicate :

'kk[kk izcU/kd ds gLrk{kj

Signature of Branch Manager

Ø-la- uke QkeZ Hkjus dh rkjh[k deZpkjh ds lkFk ukrsnkjh D;k muds lkFk jg ;fn ugha] rks vkokl
SI. No. Name dks vk;q@tUe&rkjh[k Relationship with the jgs gSa\ crk,a dk LFkku n'kkZ,a
Date of Birth/Age as on Employee Whether residing If' No, state Place of
date of filling form with him/her. Residence
gk¡@Yes ugha@No dLck@Town jkT;@State
 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)
1.
2.
3.
So on.

Statement
1. Name of employee in full
2. Sex
3. Religion
4. Whether unmarried/married/widow/widower
5. Department/Branch/Section where employed
6. Post held with Ticket No. or Serial No., if any
7. Date of appointment
8. Permanent address:
Village Thana Sub-division
 Post Office District State

Place:
Signature/Thumb-impression of the
Employee
Date:

Declaration by Witnesses

Nomination signed/thumb-impressed before me

Name in full and full address of witnesses. Signature of Witnesses.
1. 1.

2. 2.

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

Date: Name and address of the establishment or

rubber stamp thereof.

Acknowledgement by the Employee

Received the duplicate copy of nomination in Form 'F' filed by me and duly certified by the employer.

Date: Signature of the Employee

Note.—Strike out the words/paragraphs not applicable.