iofteszor vive / Regn No STS 9g | STH 19 / Fom 19 (sees araicsarem sucheresfie / dacs esraiesa rraer Bs fsx / For Office Use only) TELEPHONE NO. asstardt sifarsa fore atsren, 1952 SuPLovens: ig YEES astarit wfter fafer ats, 1952 ctananrs.} EMPLOYEES' PROVIDENT FUND SCHEME 1952 BRO. nee softer Paco ars eres fea Fae crete ar ape eerzzren cor (ger ge) | GRIEVANCES — 647 00 25 ae oe vite AR oA or car aes eer ee sites AAR einer B afer Geer SIT HT Sei (69) Formto be used by a Major Member of the Employees Provident Fund Scheme, 1952 [aa aatet Rrenajra Soares ach. forciaiming the Employees Provident Funds Dues (para 69) ae cori soesen 1 (geen “gan wat” | aren “ ore Bei "/ Referto the "Instructions" ) “This Form ie available 1 Srorrerare vie ( qjaves oterars ) waza aor omer ( ere overd @ ) Name of the member (in Block letters ) 2” -wdieia ala ( bar adie ala oe al at Ranft order az) {Reem a ane (ar OF at ott Fee aefBesott @s anos 3) Father's Name (or Husband's name in case of married women) 3. -Sererg sar Brose /ziedared armen diet ean eee ofa eT preston / zeae est one & cen re ree offer are Brgaer en Name & Address of the Factory / Establishment in which the member was last employed. of cost 4, afer fefh zane is. | ovfPren flxf@r zara zizemt / P. F. Account No. MH/ 5. tesSt Ravan aria / atest ahaa afl AR 6. sites ascend aoren / ates’ Olsay aor emrzo1 Date of leaving Service Reason for leaving Service 7, Sacaaarerendl coroner Tigeh ren ( Gare Overeet ) / Sema ast Gel wen (wae overs) Full Postal address (in Block Letters ) sft | sftarelt | geen Shri. / Smt. / Kumari ar ge | cet / A ascen | got / ceo / qT S/o. Wo. Dio. ‘Hesaties | fret | Pin Code No. 8 aka ‘earstes teat sen west deh crear ois gore Bt FRY ‘ar fScoroht eiemer ( / ) ove “gor a=zrdh MODE OF REMITTANCE aifter fase ves aftas az askees dt (/) ‘fas’ oom! (7_) Puta 'tick’in the box against the one opted. (=) awaatar aeftoités rsa ( ) xesn si. 6 ond az dem wera (@) 3 eed ow onftoiiée grr (0) wei. 7 as are 0 a wa oe {@)_ By Postal Money Order at my cost (__ ) tothe address given against item No. 7 (22) zacoar uodeneere weet des earearez (_) sae des aren aan, ea (erfirpa aes) sean des/ctez off) (+) S. B, Account No. J reardl a a8 aro aseserd ( dha ureett ones sitseft ome) (a) aR after aod ge A weet des ere. gas3 vig aia, ener a igh wer (orepefite thas) escort das grave) a ran pea iss eat li . Name of the Bank Full Address of the Branch ‘Sq Sedhfeser Ses ed ston one | ( orfeaar safe zefte: after Gt org #1) (©) By account payee cheque to be sent direct to Bank for credit to my S.B. Alc. ( Schedule Bank / Co.op. Bank / P.O. } under intimation to me (Advance stamped Receipt furnished below) —§_xeforra efter att 2s fu oferara / Contribution for the Current Financial Year : ‘aren Giver rat / a 20-20 Alle. No. MH! cesta [Rabo on fren Employers Sh] pga apy | RIN m aren aH ogee fen [a R10 em | amet a ea arb en [Workers Share| ese tia] “Seer aan (pe ae (aie amg 1) Monty | Amount of | 5. rf. |"Epraitererce | PENSION | Retund of | No. of days perod cee EP | between tom | ALND ‘Ady. | ol hon-contbuting & 8.19% tf amy)| _Contibuion mea (Fay) 7 2 3 mn 4b = é z oats: April 20, ae May Bre (eo) ses® waa ah ferRa(at ears oA) la) Date of Leaving ali sere, i any orn August Bewez Sept. oma (a) ed aaa ae nae fe) Reasene tor Leaura Now series, fary Baeaz Dee sore san. weet Feb. 2 ard March Total pram sive -5 FORMNO.-5 Preteen a xenon ( wratera af apex ut) / Signature of the employer (with office sea) a] aakenfesr ‘Rei wa 7 = reas | onal a (zere orerar at) | (ar RtaiBerates ts | xy weed Reet deri wi as at) aaa | ora (cron aes fate |store eq) athor’s Name “oll erie of previous Ne No. (or husbangs name Sex | Dale ot | Sanace as on he ate | RETA st Name of the Employee. | in case of married | Date Joining | ofjeining the Fund Ne. {in block ltrs} Woman) of the Fund | fenciose Scheme birth Cconeate if appleabie) sat zizem - 10 FORM NO. - 10 Rama | aaa areas Seger ee a efter | ee a a (sae ore). | SET) Fathers Name or husbands nama se | Ae No.| Name ofthe Employee | husbands nar Date ot Reason of . io {in Block letters) Sec eTaeS | eaving Service leaving Service Fens aries /Date (Prehaen as eeners ( apraforar at ez afer ) / signature of the employer (with office sea)oe aren Carers aTEsaRTAN wrt Boch overs are A ane arose overran ome = See ear Gm rekerenegrer aenfeset flor are ec, ee rtoramnst fOr art wer at sat & | Information to be furnished by the Employer if the claim Form is attested by the employer. sronfOrer azar al (2s aStes oforarar fererorer ares otererorIaeay ores OT. Sronfore faven srrer 2 fas grater oferarat PBrter anfBras frac ot zrfsnftsr fer eran = | Certlfied that the above contributions have been included in the regular monthly remittances, ekerars ongerewe WA Sach on j starch French QoeSt ont sft a Ae aver ears fou Joe ese I ‘The applicant has Signed /thumb inpressed before me. ‘roves Risen Rigas ofan zt anerarsh Oi | sore faba sre Tere (Brahe ex enfgper ones as eeTare ‘oforearch feet Signatuere of the employer or authorised officer wea a exenere an ang / ame ere 2 ofeys aor fever Saoies / Dated Signature or Left / Right hand thumb impression of, the member anfrer-an ry on cera FRIST EAT az va aitez Designation and seal * Stasi / ores Encl asia creer rerio | ahas Sat at ast at dewon / Declaration of non-employment A oftrergctas afereiae aszet ast, arg ex ors rere gger asaites ealt chor anfBat teres ccattarezt fea sen dates anf (fr asrerar sare] one orem arent are A afta wen ¢ fe aa afer ‘Brit ar af orfeeer areal 2g onan aft rie wt crores Ge 2 sre wT raft Hi fast elt SeaDoo ot Sree anf HAR orf rey 2, aerar arél fee 2 | \ caslate that T have not been employed in any Factory/establshment to which the act applies fora cortinunous period not eee then 2 onthe immediatly preceeding date of the my application fo fnal withdrawal of my Provident Fund money. ee ee Barererdh w@h | Soren fer Sram aver Siaroerrt fren D M Y i : r -zrear & Beeene av ang J en wre & ofS wer Few fraie/ Dated: I Signature or Left / Right hand thumb impression of the member arenas Gra aTadt / oifara creat zie / ADVANCE STAMPED RECEIPT ( sre ets os. 8 ( a) ove eomengre et arovPes oreo) ( asacs seer 6 ( a) aft zen at ten ome ) (fo be furnished only in case of 8 (b } above ) “Arcana ever deer afte Bro ore, em ones see asrafess, — — — atom erases iee8h > ag corre get Pept deer ae Fed — — — 5 od at Hes are dT gE |Received a sum of Rs, (Rupees. only ) from Regional Provident Fund Commissioner /Otficer-in-charge of S. R.0.. saving Bank Account towards the settlement of my Provident Fund account, by deposit in my am ariaeg a0 srr * ae eeiftdseu aheesar sci wtorlhdh casa flog oa. } ax aor wef A anftea AE omgericat / sont ones / sae feare oom sprafeserger arzefl rs . fc Ro * Sf after Ff omgaet / som ones saaer Stamp spraerengrat ora &s fu her sm 1 i woreerht a8 | orem set sre * The space should be left blank which shall be s Sh ft filled in by Regional Provident Fund Commissioner / asec ‘ OffGar: In= change of Alo ‘wae 8 eeenere on and / end ere 2s cig’ aot fren ‘Signature or Left/ Fight hand thumb impression af the member (mgr worafesar &s srt &5 f850/ For tho uso of Commissioners Otfice) ‘ee ef | yeh Brent sen ore co a, 21 as / we eee ARETE 3 (8%. ) mee 9 ( zee) 3 ste alt Aic. settled in part / Full Entered in F. 21 A & W/d. Register / From 3 ( FPF ) / Form 9 ( Revised } fesftres / Clerk srgeret aaaras / Section Supervisor (= Under Rs. a onez ) pase cleanin tt pines Des is ani Rothe | nnn Freaias ufbs agoreret Fe BP. |. No. sof oft M.O/ tas | Cheque waren zi. Account No. ——______ orgprrer_ Section P.1. CODE Passed for Payment for = Rs. Ua TSE (in Worse ig, eis eet —_-ToOoeS —_— rg atree: wotbotiée weiter (afte) M. ©. Commision ( a ee softs rer qorenen ah ouctereft gyer at ( Net amount to be Paid by M.O. ) fRsties/Date : = Bera omges/ Asstt. Commissioner ( eos orgprrer a erator ds fv ) (For Use in Cash Section ) Dens adh des waren i. 01 at are ai. aed. fees A emer gre geen sen seen | Paid by inclusion in Cheque No. Dated vide Cash Book ( Bank) Account No. 01 Debit item No, ong. wet. / 8. S. won. / AC. a. on. / RC, srfttgféerat / REMARKS