NAME : Mr. H.Q. : BANKA/C NO.

DESIGN. : DATE OF JOINING: BANK NAME:

_ _ _

REQUIRED DOCUMENTS

01. 02. 03.

Hand Written Joining Passport Size Photo

Letter
3 (Three)

Family Group Photo (Post Card Size) Resume Identity (a) Proof

2 (Two)

04. 05.

Voter Card / Driving Licence

06. 07.

Bank Passbook Copy Permanent Rersidence (a) Ration Card PAN Card Personal Details on Company's Age Proof Certificate Educational Certificates Form + Form-II
+ Form-2)

Address Proof

08. 09. 10. 11. 12. 13. 14. 15. 16.

Format.

ESI Set Sign (Declaration

Form 'F' (Gratuity - Nomination) Resignation

&

NOC of Previous Company

Payment Sheet Apptt. Letter/Offer Letter

NOTE

ALL DOCUMENTS TO BE SIGNED BY THE EMPLOYEE

********************

MULTANI PHARMACEUTICALS LIMITED

H-36, Connaught Place, New Delhi-11 0001

Mobile : 0-96543-50710, 0-96543-50711, 0-96543-50712

e-mail: multaniayurveda@hotmail.com, multaniayurveda@yahoo.com, website: www.multaniayurved.org

PROFORMA APPLICATION FOR THE POST OF :

(In case space provided
1.

is insutticiet)!

please use extra sheets for additional

information).

Complete Name of the Applicant Father's/Husband's Name and Occupation Complete Postal Address Ph. No. E-mail address Permanent Alc. No. (with PAN Card Copy)

2. 3.

4.

Permanent Address

5.
6.

Date of Birth (a) Bachelor / Married / Spinster (b) How many members of family you have to support and your relationship with them Academic Qualification (Originals must be Shown at the time of Interview) Any Civil/Criminal Case pending against you Your complete previous experience (in detail) with salaries drawn and reasons for your having left your previous employers, if any and copies of appointment letter and certificates obtained while leaving previous services should be attached Whom served/Service Salary Years Reason for leaving Name of Job

7. 8. 9.

10.

How many languages do you know? (only tick) (a) English (ReadinglWriting) (b) Hindi (ReadinglWriting) (c) Any other language Do you have knowledge of Computers Salary Expected

11.

12. 13.

Anything more you would like to Convey regarding yourself

I hereby declare that all the above mentioned information is true to the best of my knowledge and nothing has been concealed. DATED: SIGNATURE OF APPLICANT Please Note that each & every column MUST be filled by the Applicant. Subject to New Delhi Jurisdiction only.

Please write precise amount. Do not write 'Negotiable' I 'As per company norms'

~~

DECLARATION
m
(lfi) ~
(A) 1.

FORM

q;;f ~ am 'IRT ~ I q;pf if; WI' 1lffi1i'1t i31l'!iI\ if; ~ ~ '1ft wm( ;;rR ~ I q;pf 'lIB B ~ 1fto TO 1R 1ft 'l{ ~ 'lit 1Wft-'I!ifef 1:f<f ~ ~ I To be filled in by the employee after reading instructions overleaf. Two Passport size photographs are to be attached with this form.

oqfil<r

'liT ~

(~)~'liT~

INSURED PERSON'S PARTICULARS >It'Ir~ Insurance No.

'll'!(~~if)

(8)

EMPLOYER'S PARTICULARS

9.

~'litW~
Employer's Code No.

10. ~

'lit iMl:r

<l'f

Name (in block letters)

m!'lf<l'liT'll'!

Date of Appointment

r-_.=D.=aL.....---+_...:.:M.:.=o"-'nt::.:h_-+-----'Yc:e.=a!-r --u

Father's / Husband's Name

--"R--iMl:r-----.---'--~--.----~----,---<l'f----Date of Birth

11. ~ 'liT 'll'! 'I<IT Name & Address of the Employer

'*'

r-_.=D.=aL.....---+_...:.:M.:.;:o"-'nth=----+_-"-Ye.=ca""r_--tI

~R
Marital Status
11--'--

~/~~
M / U / W
..-- __

6.!Wr
Sex

~~
Male/Female

'R\JIR 'I<IT Present Address

8. ~

"-- __ --'--1112. 'I<IT Permanent Address

if

W ~ <IT ''!'IT

In case of any previous employment please fill up the details as under: ~;ftlrr~ Previous Ins. No. Employer's Code ~o.
~'liT'll'!q'I<IT

(ili)

(a) Pin Code

(1if)~W~

~~~
~

ITI----r-TII
'I<IT

~~~
~

Pin Code

ITI----r-TII
'I<IT

(b)
('I)

'I'<R~~

'I'<R~-~

Tel. No, / E-mail Address

Tel. No. / E-mail Address

~'IR'l'l

(c)

Name & Address of the Employer

'I'<R~-~

'I<IT

Dispensary
('I) ~

Tel. No. / E-mail Address

'lit ~

if ~

(C) DETAILS OF NOMINEE

'll'! / Name

U/S

<f; ~ <f; ~ ili:U.~. ~ 1t.~" 'lit!ITU \9V'Ii.U.~. (~) ~ 1t.~o <f; ~ ~<..)<f; ~ ~ <f; oQftl 71 of the ESI Act, 1948/Rule 56(2) of the ESI (Central) Rules, 1950 for payment of cash benefit in the event of death. ~ / Relationship
'I<IT / Address

l! ~
1fuR lRWI

m 'liT 'N-f ~M t

$rrrr

'lffiII1'IiUft{

fl\; iI1: i!TU lRWI ~

I

lJlIT o4m

itft ~

'*'

fimffi <f; ~

~I l! ~

qftqr{ <f; ~

if ~

'lit

1fRT

1~ ~

<f;

I hereby declare that the particulars given by me are correct to the best of my knowledge and belief. I undertake to intimate the Corporation any changes in the membership of my family within 15 days of such Change.

~<f;~ Counter signature by the Employer

oqfil<r <f; ~/~

f.mr;f

Signature / T.I. of IP

m~~
Signature with seal

(If)
(0)
l!i ~.

oqfil<r <f; ~ 'liT ~I FAMILY PARTICULARS OF INSURED PERSON

'll'!

<& ~
Name

q;flf ~ I

'lit ort\1if "R 'lit ort\1if

~<f;Wl

~
Relationship with the Em 10 ee

'l'!f~W1 W ~ ~

~ 'Itt <IT '*"ffi

~ <OOc(

'liT

Date of Birth / Age as on date of fillin form

if

Whether residing with him/her? I Yes 'Itt I No

'N

If 'No', state lace of Residence 'I'R I Town <1"'1 I State

q;.U.~. f:r'rr1~ WWf '!'I ESI Corporation Temporary Identity Card

(~

'lit iMl:r ~ ~'Iffi G<6 ~)

(Valid for 3 months from the date of appointment)

'lit iMl:r /

Date of appointment ~I Dispensary

('!iIir<f;~~) (Space .tor Photograph)

FORM 11 (Revised) ;;. __ 11111.1111. .. 1

:';;;::;':'::::;:~:::::';::':':'::":'"

Declaration by a person taking up employment in an establishment in which the Employees' Provident Funds & Family Pension Fund Scheme enforce
I, do hereby solemnly declare that :(a)

S/o/W/o/O/o

I was employed in M/s

(Name and full address of the establishment)

and left service on ...................... (b) I was member of Fund from was/were to

prior to that, i was employed in from to

. .

provident Fund and also/but not of the Pension and my account number(s) .

(c) I have/have not withdrawn the amount of Provident Fund/Pension Fund. (d) I have/have not drawn any superannuation benefits in respect of my past service from any employer. (e) I have/have not never been a member of any Provident Fund and/or Pension Fund. (f) I am drawing/not drawing Pension under EPS 95.

(g) I am a holder/not holder of Scheme Certificate. (h) Scheme certificate surrendered/not surrendered.

Date

:..

Signature or left hand thumb 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./Miss
(Name of Employee)

is appointed as
(Designation)

in M/s

,
(Name of the Factory/Establishment)

with effect from

. (Date of appointment)

Date

Signature of the Employer/Manager or other Authorised Officer

N.Be : The principal employer should have filled it up also in respect of employees to be employed by or through a contractor.
;;!l Suppliedby :Jain Book Agency (South End) 1,AurobindoPlaceMai1let, NearGreenPai1lChurch,HauzKhas,NewDelhi-16.Ph. : +9111 26567066/41755666 . ~\ Fax: +91 1141513850 E-mail: sales@jainbookagency.com Website: www.jainbookagency.com PRICE: Rs.1.00 +VatExtra

CODE NO. 42758

Nomination and Declaration forlp for Unexempted/Exempted Establishments

Declaration and Nomination Form under the Employees' Provident Funds and Employees' Pension Scheme
(Paragraphs 33 & 61(11 of the Employees Provident Ftlnd Scheme, 1952 and Paragraph 18 of the Employees' Pension Scheme, 19951 J. Name (in Blockleiters) Father' s/Husband' s Name Date of Birth Sex Marital Status Account No. Address Permanent

2. 3. 4.
5. 6. 7.

................. -

Temporary

...............................................................................

, ..

8.

Date of Joining PART - A (EPFI

I hereby nominate the personlsl/ccncel the nomination made by me previously and nominate the personls] mentioned below to receive the amount standing to my credit in the Employees' Provident Fund, in the event of my death.

1. 2.

"Certilied that Ihave no family as defined in para 2(g) of the Employees' Provident Fund Scheme, 1952 and should Iacquire a family hereafter the above nomination should be deemed as cancelled. "Certified that my father/mother is/are dependent upon me. Signafure or thumb impression of the subscriber

. PART B (EPS) (Para 18)

I hereby furnish below particulars of the members of my family who would be eligible"toreceive widowl children pension in the event of my death.

T. 2. 3. 4. 5. 6.
Certified that I have no family as defined in para 2{vii) of Employees' Pension Scheme, 1995 and should Iocquire a family I shall furnish particulars thereon in the above form. . I hereby nominate the following person for receiving the monthly widow pension {admissible under para 162{al(il and {ii! the event of my death without leaving any eligible family member for receiving pension.

h~r'l'!ntfl'!r

Signature or thumb impression of the subscriber

out whichever is not applicable

tERfJFltAtE BY EMpLOYER
Certified that the above declaration and nomination has been signed/thumb impressed before me by Shri/Smt,/Kum . ............................. employed in my establishment after he/she has read the entries/entries have been read over to him/her by me and gotconfirmed by him/her.

.-----------------,
Place: .
Rubber Stamp of Establishment

.
Signature of the employer or other Authorised Officers of the Establishment

Designation

:~

'

Dated the
~~

,.y;

Supplied by: JBAlJAINA BOOK ~~ENCY (Sales), C-5, C~nnaught .~Iaee, New Delhi-llOO01 .Ph.: 23~ 1639.5/96/97 Fax: E-mail: sales@JaJnabookageilcy.com WebSIte: wwwjainabookagency.com for on Ime ordenng Price: Rs 1.00

+ ,sales tax

Payment of Gratuity
[SEE SUB-RULE (1) OF RULE 6]

NOMINATION
To .

(Give here name or description of the establishment with full address) 1. Slui/Smt.lKumari , (Name in full here) whose particulars are given in the statement below, hereby nominate the person(s) mentioned below to receive the gratuity payable after my death as also the gratuity standing to my credit in the event of my death before that amount has become payable or having become payable has not been paid and direct that the said amount of gratui ty shall be paid in proportion indicated against the name(s) of the nominee(s).
2.

I hereby certifythat the peson(s) nominated is alare memberfs) of my family within the meaning of clause (h) of section (2) of the Payment of Gratuity Act, 1972.

3.r

hereby declare that I have no family within the meaning of clause (h) of section (2) of the said Act. (a) My father/mother/parents is/are not dependent on me. (b) My husband's father/mother/parents is/are not dependent on Ply husband.

4.

5.

I have excluded my husband from my family by a notice dated the authority in terms of the provisio to clause (h) of section 2 of the said Act.

to the controlling

6.

Nomination made herein invalidates my previous nomination.

Nominee(s) Name in full with full . address of nomineets) l.

;Relatioruhip with Age of the employee nonnnee

Prportion by which the gratuity will be shared ..

2.

.J.

..,

4.

as on

Stateillent
". \

Name of employeetin
2.

full)

. .
e .. , ...........

Sex Religion Whether .unmarried/married/widow/widower Department/Branch/Section where employed ,

j. _ _.

3.
4. 5.

. ...................................................................................... . .

6 7
8.

Post held with Ticket or Serial No., if any Date of appointment Permanent address .. . Village Post Office Thana District......... . ", ,,'.. ,',

Sub-division State Signature/Thumb Pin impression

. .

Place Date.

of the employee

Declaration by witnesses Nomination signed/thumb impressed before me. Signature of witness

Name in full and full address of witness'

Place .. Date .

Certificate by the employer

Certified that the particulars of the above nomination have been verified and recorded in this establishment. Employer's Reference No. if any. Signature of the employer/officer authorised Designation Name and address of the establishment or rubber stamp thereof Date . Acknowledgement by the employee

Received the duplicate copy of nomination in Form 'F' filled by me and duly certified by the employer.

Date

Signature of the employee

Note :- Strick out the words/paragraph not applicable.

Supplied by : Jain Book Agency (Central) 5061/1, Sant Nagar, D.S.Gupta Road,Opp. Perhlad Market, Karol Sagh, N Delhi-OS.Ph. : +91 11 44332211 & 47528979, Fax: +9111 47528978 E-mail: central@jainbookagency.com Website: www.jainbookagency.com . MRP: Rs. 2.00