Location via proxy:   [ UP ]  
[Report a bug]   [Manage cookies]                

GATEPASS sample

Download as pdf or txt
Download as pdf or txt
You are on page 1of 11

CONTRACT WORKMEN INFORMATION

UNIQUE ID NUMBER :

CONTRACTOR NAME : Truetech Vision Industry Pvt. Ltd


SUB-CONTRACTOR NAME : NA
UNDER SUB CONTRACTOR NAME : NA
PO NUMBER / DATED 8500006249 PO. VALIDITITY FROM

CL. NAME MANISH TRIVEDI

FATHER / HUSBAND NAME SANJEEV KR TRIVEDI

AADHAR NUMBER 219978974276

NAME OF THE BRANCH HDFC BANK

ACCOUNT NO. 50100172790097


PHOTO
BANK IFS CODE HDFC0000014

UAN NUMBER 100797828027

DESIGNATION HR MANAGER

ENGAGED DATE 15/12/2024

DATE OF BIRTH 07/01/1994

GENDER MALE / FEMALE MALE MARITAL STATUS MARRIED

CATEGORY SKILLED UNSKILLED / SEMI SKILLED / SKILLED / HIGHLY SKILLED

PF NO. PYBOM13729140000048725 ESI /WCI NO. 3601608782

SAFETY TRAINING

Present Address Permanent Address

ADDRESS
MIG-1/8, PANDIT RAVISHANKAR 9, NABA KUMAR KAR LANE
SHUKLA NAGAR, KORBA, SALKIA, HOWRAH- 711106
CHATTISGARH- 495677
ALLOWANCE PER
WAGE PER DAY 1166.67 NA
DAY
INCENTIVE PER DAY ANY OTHER WAGES

PHONE NO. 9073677368 EMAIL ID NA


IN CASE OF EMERGENCY PERSON TO Truetech Vision
MOBILE NUMBER 7439562173
BE INFORMED Industry Pvt Ltd
RELATIONSHIP OF
NOMINEE NAME NEHA KEDIA WIFE
THE NOMINEE
WHETHER MAIN CONTRACTOR OR SUB CONTRACTOR MAIN MAIN / SUB

IF SUB CONTRACTOR WRITE MAIN CONTRACTOR NAME NA

IDENTIFICATION MARK 1 :
QUALIFICATION : B.COM BLOOD GROUP A+

CONTRACT IN - CHARGE SIGNATURE WORKMEN SIGNATURE


Background Verification Form

अ. - उद् घोषणा

म OMPRAKASH KENWAT पु /पु ी/धमप ी SONU RAM KENWAT


उ लगभग 27 वष आधार नंबर 221496947315
िनबासी AT-BHATHAPARA,KHARSIA,TUREKELA,Dist:Raigarh, Chhattisgarh,496661
यहाँ घोषणा करता ँ की म भारत का नाग रक ँ । दे श की िकिसस भी ायालय म मे रे िब कोई भी
आपरािधक करण लंिबत नहीं ह। यहाँ भी की भारत म िकसी भी ायालय ने िकसी भी आपराध हे तु मु झे दं िडत
नहीं िकया है । यिद सं गठन ारा मे रे िब ऐसे िकसी भी आपरािधक मामले का सं ान िलया जाता है जो अब तक
काश म नहीं आया हे तब ऐसी प र थित म मे रे िब यथोिचत कायवाही की जा सकेगी िजसमे से वा की समा
भी शािमल है ।

थान : KORBA
िदनां क : 21/05/2024

ाथ के ह ा र

ब. ठे केदार की उद् घोषणा

म SADANANDA MAHATO पु /पु ी/धमप ी DASHARATH MAHATO


उ लगभग 50 वष आधार नंबर 888134656159
िनबासी RANGAMATI,P.S. -ARSHA,Dist:Purulia,WestBengal,723201
मे सस Amit Engineering Services की और से यह घोषणा करता
ँ की उ कामगार/कमचारी का नैितक च र अ ा है । पु िलस के अिभलेख म इनके िब कोई
भी मामला दज नहीं है ।

थान : KORBA
िदनां क : 21/05/2024

ठे केदार के ितिनिध के ह ा र एवं पदमु ा

कायालयीन उपयोग के िलए :

कामगार का नाम
युआईडी

ा कता अिधकारी के ह ा र
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) O M P R A K A S H K E N W A T 0 0
MR. MS. MRS.

(PLEASE TICK)

2) DATE OF BIRTH D D M M Y Y Y Y
2 6 0 1 1 9 9 7

3) FATHER'S/ MR. S O N U R A M K E N W A T
HUSBAND'S NAME

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


(PLEASE TICK)

5) GENDER MALE FEMALE TRANSGENDER


(PLEASE TICK)

6) MOBILE NUMBER 9 3 4 0 9 3 3 4 1 4
(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):
A. PREVIOUS EMPLOYMENT DETAILS
10)THE DETAILS OF THE UNIVERSAL ACCOUNT NUMBER (UAN) OR PREVIOUS PF MEMBER ID:
UAN 1 0 2 0 7 1 9 8 1 3 9 1
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) ILLITERATE NON- MATRIC SENIOR GRADUATE POST DOCTOR TECHNICAL /


EDUCATIONAL MATRIC SECONDAR GRADUATE PROFESSIONAL
QUALIFICATION Y
(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


KYC DOCUMENT TYPE NAME AS ON KYC NUMBER REMARKS, IF ANY
17) KYC DETAILS DOCUMENT
BANK ACCOUNT-1* OMPRAKASH KENWAT 763701011003051 VIJB0007637

NPR/ AADHAAR OMPRAKASH KENWAT 221496947315

PERMANENT OMPRAKASH KENWAT


ACCOUNT NUMBER
PASSPORT

DRIVING LICENSE
ELECTION CARD
RATION CARD
ESIC CARD OMPRAKASH KENWAT 5918517771

* 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
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 :21/05/2024

PLACE : KORBA SIGNATURE OF MEMBER

DECLARATION BY PRESENT EMPLOYER


A. THE MEMBER Mr./Ms./Mrs. OMPRAKASH KENWAT HAS JOINED ON 20/05/2024 AND HAS BEEN ALLOTTED PF
MEMBER ID 102071981391
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 MEMBER102071981391


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 : 21/05/2024 SIGNATURE OF EMPLOYER WITH SEAL OF ESTABLISHMENT


FORM-1
NOMINATION AND DECLARATION FORM
(See Rule-3 under payment of Gratuity Rules)

1- Name of the person making nomination - OMPRAKASH KENWAT


2- Father's/ husband's name- SONU RAM KENWAT
3- Date of birth- 26/01/1997 4- Sex- MALE 5-Marital Status- UNMARRIED
6-Address: Permanent: AT-BHATHAPARA,KHARSIA,TUREKELA,Dist:Raigarh, Chhattisgarh,496661
7-Temporary: NEAR AMBIKA MANDIR, BHADRAPARA, BALCO NAGAR, KORBA,CG-495684

I hereby nominate the Person(s)/Cancel the nomination made by me previously and nominate the persons
nominated below to receive any amount due to me from the employers in the event to my death.

Total amount of If the nominee is mino, name,


share of relationship and address of the
Name of the Nominee's accumulations in guardian who may recessive the
Address Date of Birth credit to be paid amount
Nominee/nominees relationship
to each nominee

TERAS BAI AT- MOTHER 01/01/196 100


KEWAT BHATHAPARA, 9 -
KHARSIA,TURE
KELA,Dist:Raiga
rh,
Chhattisgarh,49
6661

1- Certificate that I have no family and should I acquire a family hereafter the above nomination
shall be deemed as cancelled.
2- Certificate that my Father/ Mother is are dependent upon me.
3-Strikeout whichever is not applicable.

Signature or the thumb impression


of the employed person.

CERTIFICATE BY EMPLOYER

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

Place: KORBA Signature of the employer or authorized officer


Date: 21/05/2024 Designation & Stamp:
FORM 2 (Revised) Annexure-X

NOMINATION AND DECLARATION FORM FOR UNEXEMPTED/


EXEMPTED ESTABLISHMENTS

Declaration and Nomination Form under the Employees’ Provident Funds and
Employees’ Pension Scheme
(Paragraphs 33 & 61 (1) of the Employees Provident Fund Scheme, 1952 and Paragraph 18 of the Employees’ Pension scheme, 1995)

1. Name (in Block letters) : OMPRAKASH KENWAT

2. Father’s/Husband’s Name : SONU RAM KENWAT

3. Date of Birth : 26/01/1997

4. Sex : MALE

5. Marital Status : UNMARRIED

6. Account No. : 102071981391

7. Address Permanent : AT-BHATHAPARA,KHARSIA,TUREKELA,Dist:Raigarh, Chhattisgarh,496661

Temporary : NEAR AMBIKA MANDIR, BHADRAPARA, BALCO NAGAR, KORBA,CG-495684

8. Date of joining : 20/05/2024

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 :

Name of Address Nominee's Date of Birth Total amount of share If the nominee is a minor name & relationship
nominee/nomine ralationship with the of Accumulations in & address of the guardian who may receive the
es Provident Fund to be amount during the minority of nominee
member
paid to each nominee
1 2 3 4 5 6
TERAS BAI AT- MOTHER 01/01/1969 100
KEWAT BHATHAPARA,K -
HARSIA,TUREKE
LA,Dist:Raigarh,
Chhattisgarh,49
6661

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.

Signature or thumb impression of the subscriber

*Strike out whichever is not applicable.


Part B (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 death.
S.N Name of the family
Address Date of Birth Relationship with the member
o. member
1 2 3 4 5
1 TERAS BAI KEWAT AT- 01/01/1969 MOTHER
2 BHATHAPARA,KHAR
SIA,TUREKELA,Dist:
3
Raigarh,
4 Chhattisgarh,49666
5 1
6

** Certified that I have no family, as defined in para 2(vii) of Employees’ Pension Scheme, 1995 and should I acquire a family
hereafter I shall furnish particulars thereon in the above form.

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

Name and Address of the Nominee Date of Birth Relationship with the member
1 2 3
1. TERAS BAI KEWAT 01/01/1969 MOTHER
2.
AT-
BHATHAPARA,KHARSIA,TUREKEL
3. A,Dist:Raigarh,
4. Chhattisgarh,496661

Date : 21/05/2024
Signature or thumb impression of the subscriber

**Strike out whichever is not applicable.

CERTIFICATE BY EMPLOYER

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

Place : KORBA
Signature of the employer or other
Authoried Officers of the Establishment.

Dated the : 21/05/2024 Designation

Name & Address of the Factory/


Establishment or Rubber Stamp Thereon
Printed On :20/05/2024

Approved Member Registration Details


Est Id : ORRKL1502350000

Note : DSC/eSign is not required in case of verified


Est Name : AMIT ENGINEERING SERVICES

1. Member

Name: OMPRAKASH KENWAT Member Id : ORRKL15023500000010263

UAN/Previous Member 102071981391

Name OMPRAKASH KENWAT

Date of joining 20-May-2024 Date of Birth 26-Jan-1997

Gender Male Marital Status Un-Married

(F)ather's/(H)usband's SONU RAM KENWAT (F)


Nationality Indian

Mobile -- e-Mail ID --

Is International Worker No

Qualification MATRIC Monthly EPF Wages as on Joining 12050

Disability Type No
Member is from Assam,
Meghalaya, Nagaland, Nepal No

Note : * means employee is not eligible to become the member of EPS 1995.
KYC Details Pending For Digital Signatory

Sl No KYC Document Document Document Information Verification


Name As Per Document
Number Status
XXXX XXXX 7315
1. AADHAAR OMPRAKASH KENWAT -- VERIFIED

1/1
EMPLOYEES' STATE INSURANCE CORPORATION
e-Pehchan Card

PERSONAL DETAILS

Name of IP : OMPRAKASH KENWAT Insurance No. : 5918517771


Date of Birth : 26/01/1997 UHID : NA
Gender : Male UAN : NA
Mobile Number : 9340933414 ABHA Number : NA
Email ID : NA ABHA Address : NA
Registration Date : 21/05/2024 Aadhaar : NA

REGISTRATION DETAILS

Marital Status : Unmarried Name of Father / : SONU RAM KENWAT


Husband
Type Of Disability : NA
Present Address : NEAR AMBIKA Permanent Address : BHATHAPARA,KHARSIA,TUR
MANDIR,BHADRAPADA,BALCO EKELA,Dist:Raigarh,Chhattisga
NAGAR,Dist:Korba,Chhattisgarh,495684 rh,496661

Dispensary / : Balco Nagar,CT (ESIS Disp.) Dispensary / : Raigarh, CT (ESIS Disp.)


IMP for IP IMP for Family

CURRENT EMPLOYER DETAILS

Employer's Code : 85000163950001001 Name of Employer : AMIT ENGINEERING


No. SERVICES

Sub Unit's Code : 59850163950011001 Date of : 20/05/2024


No. Appointment

Address of : MIG 1/170, M.P. NAGAR,KORBA Branch Office : BO - Korba,Branch Office,


Employer C.G,Dist:KorbaChhattisgarh495677 E.S.I. Corporation,Vikash
Bhawan, OldNABus Stand, 1st

FAMILY DETAILS

Name Relation Date UHID/ABHA Number ABHA UAN/ Is Residing State/District


with of Birth Address Aadhaar with IP
IP

Chhattisgarh /
TERAS BAI Dependant 01/01/1969 NA No
KEWAT mother
Raigarh

Page 1 of 2
NOMINEE DETAILS

UHID/
Name of Nominee Relation with IP Date of Birth Address of Nominee Percentage(%)
ABHA Number

BHATHAPARA,KHARSIA,TU
TERAS BAI KEWAT Dependant mother NA NA REKELA,ChhattisgarhDist:K 100
orba496661

Affix Your Family Photograph Here. (Attested and Stamped by


Employer / ESIC Official)

Signature / LTI of Registered Employee / IP

Signature / Stamp of ESIC Officer / Employer

Note:
· This e-Pehchan card affixed with photograph of family & duly attested by the Employer/ESIC Staff shall be requested for
availing cash/medical benefit.
· e-Pehchan card is a proof of registration under ESI scheme. However eligibility for various benefits depends upon the
contribution conditions. For further information on eligibility to various Benefits, please visit- www.esic.in

Printed By (Employer/User Name) : AMIT ENGINEERING SERVICES


IP Number : 5918517771
Address : NEAR AMBIKA MANDIR,BHADRAPADA,BALCO
NAGAR,Dist:Korba,Chhattisgarh,495684
Date : 21/05/2024 8:54:00AM

Page 2 of 2

You might also like