FORM -5

THE EMPLOYEES ' PROVIDENT FUND SCHEME , 1952

[Paragraph 36 (2) (a)]

AND THE EMPLOYEES ' PENSION SCHEME, 1995

[Para - 20 (4)]

Return of Employees qualifying for membership of the Employees' Provident Fund, Employees
Pension Fund & Employees' Deposit Linked Insurance Fund for the first time during the month of
May 2009
------------------------------------(To be sent to the Commissioner with Form 2 (EPF & EPS)
Name and Address of the Factory/Estt

Cybrosys Techno Solutions

------------------------------------------------------------------------------------------Neospace , Kinfrapark , Malappuram , Pin :6789089
---------------------------------------------------------------------------------------------------------------------------------------------------Code No. of Factory / Establishment
Sl.
No.

Account No.

Name of the
Employee(in
block capitals)

Date

NE/AGT/0003455/123
------------------------------------------------------------------------------------------------Father's
Name(or
husband's
name in
case of
married
women)

Date of Birth

Sex

Date of
joining the
Fund

Total period
of previous
service
as on the
date of
joining the
Fund(Enclose
Scheme
certificate if
applicable
8

NE/AGT/00
03455/123/
3

TANIA
JOSEPH

Joseph
Vincent

01 May 1950

Female

21 May 2009

1 Year 2
Months

NE/AGT/00
03455/123/
5

SYNDRELLA
RSDSDD

Faisal

23 May 1989

Female

23 May 2009

0 Year 6
Months

NE/AGT/00
03455/123/
7

STEPHAN
FERDIN

Muhammed

23 Mar 1950

Male

23 May 2009

0 Year 0
Months

NE/AGT/00
03455/123/
8

JOSEPH
MATHEW

Unni

14 Feb 1950

Male

23 May 2009

24 Year 08
Months

NE/AGT/00
03455/123/
10

RATASHA
VINCENT

Mohammed.
P

21 Sep 1988

Male

09 May 2009

1 Year 0
Months

14-06-2011
------------------

Remarks

9
Excelle
nt

Signature of the Employer or other

authorised officer of the Factory/Establishment
Stamp of the Factory/Estt.