GATEPASS sample
GATEPASS sample
GATEPASS sample
UNIQUE ID NUMBER :
DESIGNATION HR MANAGER
SAFETY TRAINING
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
IDENTIFICATION MARK 1 :
QUALIFICATION : B.COM BLOOD GROUP A+
अ. - उद् घोषणा
थान : KORBA
िदनां क : 21/05/2024
ाथ के ह ा र
थान : KORBA
िदनां क : 21/05/2024
कामगार का नाम
युआईडी
ा कता अिधकारी के ह ा र
Declaration Form
(To be retained by the Employer for future reference)
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
6) MOBILE NUMBER 9 3 4 0 9 3 3 4 1 4
(IF ANY)
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
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
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)
To D D M M Y Y Y Y
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
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.
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.
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.
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)
4. Sex : MALE
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.
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
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.
1. Member
Mobile -- e-Mail ID --
Is International Worker No
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
1/1
EMPLOYEES' STATE INSURANCE CORPORATION
e-Pehchan Card
PERSONAL DETAILS
REGISTRATION DETAILS
FAMILY DETAILS
Chhattisgarh /
TERAS BAI Dependant 01/01/1969 NA No
KEWAT mother
Raigarh
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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
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
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