Form 11

(Revised)

THE EMPLOYEES’ PROVIDENT FUNDS SCHEME, 1952 (Paragraph 34)

AND
THE EMPLOYEES’ PENSION SCHEME, 1971 (Paragraph 19)
Declaration by a person taking up employment in an establishment in which the
Employees’ Provident Funds & Employees’ Pension Scheme enforce

I Son/ wife/ daughter

(Name of Employee) ofSh.
do hereby solemnly declare that :-

(a) I was employed

in M/s (Name and Full Address of the immediate previous employer)
and left service prior to that, I was
on (Date of leaving with immediate previous employed in
employer)
fro to
(Name and Full Address of the second last m
employer, if any) (Date of joining & leaving with second last
employer, if any)

(b) I was member

of (Name of PF Trust / Address of PF Office of immediate previous employer )
Provident Fund and also/but not* of the fro to
Pension Fund m
(Date of joining & leaving with immediate
previous employer).
and my account number (s)
was/were (PF No. with Establishment Code of immediate
previous employer)
I have / have not* withdrawn the amount of my Provident Fund/Pension Fund.
(c)
I have / have not*drawn any superannuation benefits in respect of my past service from any employer.
(d)
I have / have never * been a member of any Provident Fund and/or Pension Fund.
(e)
I am drawing / not drawing * Pension under EPS 95.
(f)
I am a holder / not holder * of scheme Certificate.
(g)
Scheme certificate surrendered / not surrendered *.
(h)
*Strike out whichever is not applicable.
Date
Signature or left hand
(Date of joining of thumb
employee)
impression of the
employee
(To be filled in by the employer only when the person employed had not already been a
member of the Employees Provident Fund)
Shri/Smt is
(Designation with Co.)
. (Name of Employee) appointed
as
in
M/s with effect
(Name of the present employer ) (Date of appointment)
from
Form 11
P.F. Account (PF No. with Estt. Code of
Number present employer)

Date
(Date of joining of Signature of the
employee) Employer/Manager or Other
Authorised Officer with Office
Seal
NB:The principle employer should have filled it up also in respect of employees to be employed by or through a
contractor

Form 11