(For Unexempted/ exempted Establishments)

(Paragraph 33 and 61(1) of the Employees ' Provident Fund Scheme, 1952 &
Paragraph 18of the Employees 'Pension Scheme 1995 )
Declaration and Nomination Form under the Employees' Provident Funds & Employess' Pension Scheme
1. Name 2. Father's / Husband Name
3. Date Of Birth 4. Sex
5. Marital Status 6. Account No.
7. E Mail Address 8. Phone No.
9. Address
Permanent
Temporary
I hereby nominate the person(s)/cancel the nomination made by me previously and nominate the person(s) , mention
below receive the amount standing to my credit in the Employee' Provident Fund , in the event of my Death
PART A (EPF)
Name of the
nominee/nominee's
Address Nominee's
relationship with
the member
Date Of
Birth
Total Amount or
Share of
accumulation in
Provident Fund
to be paid to
each nominee
If the nominee is minor
,name & relationship &
address of the guardian
who may receive the
amount during the
NOMINATION AND DECLARATION FORM
11A, MAHENDRA SARKAR STREET,PS-MUCHIPARA,KOLKATA,KOLKATA,WEST BENGAL,700012
11A, MAHENDRA SARKAR STREET,PS-MUCHIPARA,KOLKATA,KOLKATA,WEST BENGAL,700012
WB/PRB/0053862/000/0000001
FORM2 (Revised)
SHYAMA GANGULY
22-Oct-1975
MARRIED
ASHOK GANGULY
FEMALE
91
,,,,,
11A, MAHENDRA SARKAR
STREET,PS-MUCHIPARA,KOL
KATA,KOLKATA,WEST
BENGAL,700012
03-Mar-1995 100 ACHINTAN GANGULY SON
*Cettified that i have no family as defined in para2 (g) of the Employees' Provident Fund Scheme,1952 and
should I acquire a familly hereafter the above nomination should be deemed as cancelled.
*strike out whichever is not applicable Signature or thumb impression of the Subscriber
* Certified that my father / mother is / are dependent upon me.
PART B (EPS)(Para 18)
I hereby furnish below particulars of the members of my family who would be eligible receive
widow/children pension in the event of my death
Sl.
No
1.
Name and Address of the family member Date Of Birth
4
Relationship with
member
5
Address
3
Name
2
11A, MAHENDRA SARKAR
STREET,KOLKATA,KOLKATA,,700012
1 ACHINTAN GANGULY 03-Mar-1995 SON
I hereby nominate the following person for receving the monthly widow pension (admissible under para 16 2(a)(i)(ii) in the
event of my death wihout leaving any eligible family member for receiving pension
**Certified that I have no family as defined in para 2 (vii)of the Employees' Pension Scheme, 1995 and should I acquire a
family hereafter I shall furnish particulars thereon in above form.
Relationship with the member Date Of Birth Name and Address of Nominee
Name and address of the Factory/
Establishment or rubber stamp thereof
Designation
Signature of the employer or the other
authorized Officers of the establishment
Place :
Date :
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 got confirmed by him/her.
CERTIFICATE BY EMPLOYER
Signature or thumb impression of the Subscriber *strike out whichever is not applicable
Date :
(For Unexempted/ exempted Establishments)
(Paragraph 33 and 61(1) of the Employees ' Provident Fund Scheme, 1952 &
Paragraph 18of the Employees 'Pension Scheme 1995 )
Declaration and Nomination Form under the Employees' Provident Funds & Employess' Pension Scheme
1. Name 2. Father's / Husband Name
3. Date Of Birth 4. Sex
5. Marital Status 6. Account No.
7. E Mail Address 8. Phone No.
9. Address
Permanent
Temporary
I hereby nominate the person(s)/cancel the nomination made by me previously and nominate the person(s) , mention
below receive the amount standing to my credit in the Employee' Provident Fund , in the event of my Death
PART A (EPF)
Name of the
nominee/nominee's
Address Nominee's
relationship with
the member
Date Of
Birth
Total Amount or
Share of
accumulation in
Provident Fund
to be paid to
each nominee
If the nominee is minor
,name & relationship &
address of the guardian
who may receive the
amount during the
NOMINATION AND DECLARATION FORM
2/13, TANWAR COLONY,,SDD MUNICIPALITY,KOLKATA,24 PGS NORTH,WEST BENGAL,700074
2/13, TANWAR COLONY,,SDD MUNICIPALITY,KOLKATA,24 PGS NORTH,WEST BENGAL,700074
WB/PRB/0053862/000/0000010
FORM2 (Revised)
ASIS GANGULY
20-Mar-1977
UNMARRIED
LATE PRASAD GANGULY
MALE
9120070962
,,,,,
2/13, TANWAR COLONY,,SDD
MUNICIPALITY,KOLKATA,24
PGS NORTH,WEST
BENGAL,700074
01-Jan-1955 100 NOMITA GANGULY DEPENDENT MOTHER
*Cettified that i have no family as defined in para2 (g) of the Employees' Provident Fund Scheme,1952 and
should I acquire a familly hereafter the above nomination should be deemed as cancelled.
*strike out whichever is not applicable Signature or thumb impression of the Subscriber
* Certified that my father / mother is / are dependent upon me.
PART B (EPS)(Para 18)
I hereby furnish below particulars of the members of my family who would be eligible receive
widow/children pension in the event of my death
Sl.
No
1.
Name and Address of the family member Date Of Birth
4
Relationship with
member
5
Address
3
Name
2
1
I hereby nominate the following person for receving the monthly widow pension (admissible under para 16 2(a)(i)(ii) in the
event of my death wihout leaving any eligible family member for receiving pension
**Certified that I have no family as defined in para 2 (vii)of the Employees' Pension Scheme, 1995 and should I acquire a
family hereafter I shall furnish particulars thereon in above form.
Relationship with the member Date Of Birth Name and Address of Nominee
NOMITA GANGULY,2/13, TANWAR COLONY,,SDD
MUNICIPALITY,KOLKATA,24 PGS NORTH,WEST BENGAL,700074
01-Jan-1955 DEPENDENT MOTHER
Name and address of the Factory/
Establishment or rubber stamp thereof
Designation
Signature of the employer or the other
authorized Officers of the establishment
Place :
Date :
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 got confirmed by him/her.
CERTIFICATE BY EMPLOYER
Signature or thumb impression of the Subscriber *strike out whichever is not applicable
Date :
(For Unexempted/ exempted Establishments)
(Paragraph 33 and 61(1) of the Employees ' Provident Fund Scheme, 1952 &
Paragraph 18of the Employees 'Pension Scheme 1995 )
Declaration and Nomination Form under the Employees' Provident Funds & Employess' Pension Scheme
1. Name 2. Father's / Husband Name
3. Date Of Birth 4. Sex
5. Marital Status 6. Account No.
7. E Mail Address 8. Phone No.
9. Address
Permanent
Temporary
I hereby nominate the person(s)/cancel the nomination made by me previously and nominate the person(s) , mention
below receive the amount standing to my credit in the Employee' Provident Fund , in the event of my Death
PART A (EPF)
Name of the
nominee/nominee's
Address Nominee's
relationship with
the member
Date Of
Birth
Total Amount or
Share of
accumulation in
Provident Fund
to be paid to
each nominee
If the nominee is minor
,name & relationship &
address of the guardian
who may receive the
amount during the
NOMINATION AND DECLARATION FORM
693, EAST SINTHEE ROAD,DUMDUM,KOLKATA,24 PGS NORTH,WEST BENGAL,700030
693, EAST SINTHEE ROAD,DUMDUM,KOLKATA,24 PGS NORTH,WEST BENGAL,700030
WB/PRB/0053862/000/0000011
FORM2 (Revised)
AYAN CHAKRABORTY
10-Dec-1985
UNMARRIED
DHIREN CHAKRABORTY
MALE
ayanchakraborty000@gmail.com
,,,,,
693, EAST SINTHEE
ROAD,DUMDUM,KOLKATA,24
PGS NORTH,WEST
BENGAL,700030
16-Apr-1960 100 SUKLA
CHAKRABORTY
DEPENDENT MOTHER
*Cettified that i have no family as defined in para2 (g) of the Employees' Provident Fund Scheme,1952 and
should I acquire a familly hereafter the above nomination should be deemed as cancelled.
*strike out whichever is not applicable Signature or thumb impression of the Subscriber
* Certified that my father / mother is / are dependent upon me.
PART B (EPS)(Para 18)
I hereby furnish below particulars of the members of my family who would be eligible receive
widow/children pension in the event of my death
Sl.
No
1.
Name and Address of the family member Date Of Birth
4
Relationship with
member
5
Address
3
Name
2
1
I hereby nominate the following person for receving the monthly widow pension (admissible under para 16 2(a)(i)(ii) in the
event of my death wihout leaving any eligible family member for receiving pension
**Certified that I have no family as defined in para 2 (vii)of the Employees' Pension Scheme, 1995 and should I acquire a
family hereafter I shall furnish particulars thereon in above form.
Relationship with the member Date Of Birth Name and Address of Nominee
SUKLA CHAKRABORTY,693, EAST SINTHEE
ROAD,DUMDUM,KOLKATA,24 PGS NORTH,WEST BENGAL,700030
16-Apr-1960 DEPENDENT MOTHER
Name and address of the Factory/
Establishment or rubber stamp thereof
Designation
Signature of the employer or the other
authorized Officers of the establishment
Place :
Date :
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 got confirmed by him/her.
CERTIFICATE BY EMPLOYER
Signature or thumb impression of the Subscriber *strike out whichever is not applicable
Date :
(For Unexempted/ exempted Establishments)
(Paragraph 33 and 61(1) of the Employees ' Provident Fund Scheme, 1952 &
Paragraph 18of the Employees 'Pension Scheme 1995 )
Declaration and Nomination Form under the Employees' Provident Funds & Employess' Pension Scheme
1. Name 2. Father's / Husband Name
3. Date Of Birth 4. Sex
5. Marital Status 6. Account No.
7. E Mail Address 8. Phone No.
9. Address
Permanent
Temporary
I hereby nominate the person(s)/cancel the nomination made by me previously and nominate the person(s) , mention
below receive the amount standing to my credit in the Employee' Provident Fund , in the event of my Death
PART A (EPF)
Name of the
nominee/nominee's
Address Nominee's
relationship with
the member
Date Of
Birth
Total Amount or
Share of
accumulation in
Provident Fund
to be paid to
each nominee
If the nominee is minor
,name & relationship &
address of the guardian
who may receive the
amount during the
NOMINATION AND DECLARATION FORM
,,,,,
WB/PRB/0053862/000/0000012
FORM2 (Revised)
BIKASH KUMAR SINGH
09-Sep-1985
MARRIED
NARAYAN SINGH
MALE
*Cettified that i have no family as defined in para2 (g) of the Employees' Provident Fund Scheme,1952 and
should I acquire a familly hereafter the above nomination should be deemed as cancelled.
*strike out whichever is not applicable Signature or thumb impression of the Subscriber
* Certified that my father / mother is / are dependent upon me.
PART B (EPS)(Para 18)
I hereby furnish below particulars of the members of my family who would be eligible receive
widow/children pension in the event of my death
Sl.
No
1.
Name and Address of the family member Date Of Birth
4
Relationship with
member
5
Address
3
Name
2
1
I hereby nominate the following person for receving the monthly widow pension (admissible under para 16 2(a)(i)(ii) in the
event of my death wihout leaving any eligible family member for receiving pension
**Certified that I have no family as defined in para 2 (vii)of the Employees' Pension Scheme, 1995 and should I acquire a
family hereafter I shall furnish particulars thereon in above form.
Relationship with the member Date Of Birth Name and Address of Nominee
Name and address of the Factory/
Establishment or rubber stamp thereof
Designation
Signature of the employer or the other
authorized Officers of the establishment
Place :
Date :
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 got confirmed by him/her.
CERTIFICATE BY EMPLOYER
Signature or thumb impression of the Subscriber *strike out whichever is not applicable
Date :
(For Unexempted/ exempted Establishments)
(Paragraph 33 and 61(1) of the Employees ' Provident Fund Scheme, 1952 &
Paragraph 18of the Employees 'Pension Scheme 1995 )
Declaration and Nomination Form under the Employees' Provident Funds & Employess' Pension Scheme
1. Name 2. Father's / Husband Name
3. Date Of Birth 4. Sex
5. Marital Status 6. Account No.
7. E Mail Address 8. Phone No.
9. Address
Permanent
Temporary
I hereby nominate the person(s)/cancel the nomination made by me previously and nominate the person(s) , mention
below receive the amount standing to my credit in the Employee' Provident Fund , in the event of my Death
PART A (EPF)
Name of the
nominee/nominee's
Address Nominee's
relationship with
the member
Date Of
Birth
Total Amount or
Share of
accumulation in
Provident Fund
to be paid to
each nominee
If the nominee is minor
,name & relationship &
address of the guardian
who may receive the
amount during the
NOMINATION AND DECLARATION FORM
5E, KALU GHOSH LANE,KOLKATA,KOLKATA,KOLKATA,WEST BENGAL,700009
5E, KALU GHOSH LANE,KOLKATA,KOLKATA,KOLKATA,WEST BENGAL,700009
WB/PRB/0053862/000/0000013
FORM2 (Revised)
BINAY SHANKAR GUPTA
16-Oct-1987
UNMARRIED
BIJAY KUMAR GUPTA
MALE
9681912389 binaygupta96@gmail.com
,,,,,
5E, KALU GHOSH
LANE,KOLKATA,KOLKATA,KO
LKATA,WEST BENGAL,700009
18-Nov-1966 100 PURNIMA GUPTA DEPENDENT MOTHER
*Cettified that i have no family as defined in para2 (g) of the Employees' Provident Fund Scheme,1952 and
should I acquire a familly hereafter the above nomination should be deemed as cancelled.
*strike out whichever is not applicable Signature or thumb impression of the Subscriber
* Certified that my father / mother is / are dependent upon me.
PART B (EPS)(Para 18)
I hereby furnish below particulars of the members of my family who would be eligible receive
widow/children pension in the event of my death
Sl.
No
1.
Name and Address of the family member Date Of Birth
4
Relationship with
member
5
Address
3
Name
2
1
I hereby nominate the following person for receving the monthly widow pension (admissible under para 16 2(a)(i)(ii) in the
event of my death wihout leaving any eligible family member for receiving pension
**Certified that I have no family as defined in para 2 (vii)of the Employees' Pension Scheme, 1995 and should I acquire a
family hereafter I shall furnish particulars thereon in above form.
Relationship with the member Date Of Birth Name and Address of Nominee
PURNIMA GUPTA,5E, KALU GHOSH
LANE,KOLKATA,KOLKATA,KOLKATA,WEST BENGAL,700009
18-Nov-1966 DEPENDENT MOTHER
Name and address of the Factory/
Establishment or rubber stamp thereof
Designation
Signature of the employer or the other
authorized Officers of the establishment
Place :
Date :
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 got confirmed by him/her.
CERTIFICATE BY EMPLOYER
Signature or thumb impression of the Subscriber *strike out whichever is not applicable
Date :
(For Unexempted/ exempted Establishments)
(Paragraph 33 and 61(1) of the Employees ' Provident Fund Scheme, 1952 &
Paragraph 18of the Employees 'Pension Scheme 1995 )
Declaration and Nomination Form under the Employees' Provident Funds & Employess' Pension Scheme
1. Name 2. Father's / Husband Name
3. Date Of Birth 4. Sex
5. Marital Status 6. Account No.
7. E Mail Address 8. Phone No.
9. Address
Permanent
Temporary
I hereby nominate the person(s)/cancel the nomination made by me previously and nominate the person(s) , mention
below receive the amount standing to my credit in the Employee' Provident Fund , in the event of my Death
PART A (EPF)
Name of the
nominee/nominee's
Address Nominee's
relationship with
the member
Date Of
Birth
Total Amount or
Share of
accumulation in
Provident Fund
to be paid to
each nominee
If the nominee is minor
,name & relationship &
address of the guardian
who may receive the
amount during the
NOMINATION AND DECLARATION FORM
3 MAHAJATI NAGAR,AGARPARA,KOLKATA,24 PGS NORTH,WEST BENGAL,700109
3 MAHAJATI NAGAR,AGARPARA,KOLKATA,24 PGS NORTH,WEST BENGAL,700109
WB/PRB/0053862/000/0000014
FORM2 (Revised)
DEBABRATA RAHUT
27-Apr-1964
MARRIED
LATE CHITTYA RANJAN RAHUT
MALE
9174448347
,,,,,
3 MAHAJATI
NAGAR,AGARPARA,KOLKATA
,24 PGS NORTH,WEST
BENGAL,700109
28-Jan-1971 100 SUMITA RAHUT WIFE
*Cettified that i have no family as defined in para2 (g) of the Employees' Provident Fund Scheme,1952 and
should I acquire a familly hereafter the above nomination should be deemed as cancelled.
*strike out whichever is not applicable Signature or thumb impression of the Subscriber
* Certified that my father / mother is / are dependent upon me.
PART B (EPS)(Para 18)
I hereby furnish below particulars of the members of my family who would be eligible receive
widow/children pension in the event of my death
Sl.
No
1.
Name and Address of the family member Date Of Birth
4
Relationship with
member
5
Address
3
Name
2
3 MAHAJATI NAGAR,KOLKATA,24 PGS
NORTH,WEST BENGAL,700109
1 SUMITA RAHUT 28-Jan-1971 WIFE
3 MAHAJATI NAGAR,KOLKATA,24 PGS
NORTH,,700109
2 RITWICK RAHUT 12-Mar-1999 SON
I hereby nominate the following person for receving the monthly widow pension (admissible under para 16 2(a)(i)(ii) in the
event of my death wihout leaving any eligible family member for receiving pension
**Certified that I have no family as defined in para 2 (vii)of the Employees' Pension Scheme, 1995 and should I acquire a
family hereafter I shall furnish particulars thereon in above form.
Relationship with the member Date Of Birth Name and Address of Nominee
Name and address of the Factory/
Establishment or rubber stamp thereof
Designation
Signature of the employer or the other
authorized Officers of the establishment
Place :
Date :
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 got confirmed by him/her.
CERTIFICATE BY EMPLOYER
Signature or thumb impression of the Subscriber *strike out whichever is not applicable
Date :
(For Unexempted/ exempted Establishments)
(Paragraph 33 and 61(1) of the Employees ' Provident Fund Scheme, 1952 &
Paragraph 18of the Employees 'Pension Scheme 1995 )
Declaration and Nomination Form under the Employees' Provident Funds & Employess' Pension Scheme
1. Name 2. Father's / Husband Name
3. Date Of Birth 4. Sex
5. Marital Status 6. Account No.
7. E Mail Address 8. Phone No.
9. Address
Permanent
Temporary
I hereby nominate the person(s)/cancel the nomination made by me previously and nominate the person(s) , mention
below receive the amount standing to my credit in the Employee' Provident Fund , in the event of my Death
PART A (EPF)
Name of the
nominee/nominee's
Address Nominee's
relationship with
the member
Date Of
Birth
Total Amount or
Share of
accumulation in
Provident Fund
to be paid to
each nominee
If the nominee is minor
,name & relationship &
address of the guardian
who may receive the
amount during the
NOMINATION AND DECLARATION FORM
2 NO PREM NARAYAN,CHATTERJEE LANE,UTTARPARA,HOOGHLY,WEST BENGAL,712258
2 NO PREM NARAYAN,CHATTERJEE LANE,UTTARPARA,HOOGHLY,WEST BENGAL,712258
WB/PRB/0053862/000/0000015
FORM2 (Revised)
DEBANJAN CHATTERJEE
15-Apr-1990
UNMARRIED
DEBARTHA CHATTERJEE
MALE
8961387371 debanjanchatterjee009@gmail.com
,,,,,
2 NO PREM
NARAYAN,CHATTERJEE
LANE,UTTARPARA,HOOGHLY
,WEST BENGAL,712258
02-Oct-1962 34 DEBARTHA
CHATTERJEE
DEPENDENT FATHER
,,,,,
2 NO PREM
NARAYAN,CHATTERJEE
LANE,UTTARPARA,HOOGHLY
,WEST BENGAL,712258
02-Jan-1968 34 JHUMA CHATTERJEE DEPENDENT MOTHER
,,,,,
2 NO PREM
NARAYAN,CHATTERJEE
LANE,UTTARPARA,HOOGHLY
,WEST BENGAL,712258
10-Nov-1994 32 DIPANJAN
CHATTERJEE
OTHER
*Cettified that i have no family as defined in para2 (g) of the Employees' Provident Fund Scheme,1952 and
should I acquire a familly hereafter the above nomination should be deemed as cancelled.
*strike out whichever is not applicable Signature or thumb impression of the Subscriber
* Certified that my father / mother is / are dependent upon me.
PART B (EPS)(Para 18)
I hereby furnish below particulars of the members of my family who would be eligible receive
widow/children pension in the event of my death
Sl.
No
1.
Name and Address of the family member Date Of Birth
4
Relationship with
member
5
Address
3
Name
2
1
I hereby nominate the following person for receving the monthly widow pension (admissible under para 16 2(a)(i)(ii) in the
event of my death wihout leaving any eligible family member for receiving pension
**Certified that I have no family as defined in para 2 (vii)of the Employees' Pension Scheme, 1995 and should I acquire a
family hereafter I shall furnish particulars thereon in above form.
Relationship with the member Date Of Birth Name and Address of Nominee
JHUMA CHATTERJEE,2 NO PREM NARAYAN,CHATTERJEE
LANE,UTTARPARA,HOOGHLY,WEST BENGAL,712258
02-Jan-1968 DEPENDENT MOTHER
Name and address of the Factory/
Establishment or rubber stamp thereof
Designation
Signature of the employer or the other
authorized Officers of the establishment
Place :
Date :
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 got confirmed by him/her.
CERTIFICATE BY EMPLOYER
Signature or thumb impression of the Subscriber *strike out whichever is not applicable
Date :
(For Unexempted/ exempted Establishments)
(Paragraph 33 and 61(1) of the Employees ' Provident Fund Scheme, 1952 &
Paragraph 18of the Employees 'Pension Scheme 1995 )
Declaration and Nomination Form under the Employees' Provident Funds & Employess' Pension Scheme
1. Name 2. Father's / Husband Name
3. Date Of Birth 4. Sex
5. Marital Status 6. Account No.
7. E Mail Address 8. Phone No.
9. Address
Permanent
Temporary
I hereby nominate the person(s)/cancel the nomination made by me previously and nominate the person(s) , mention
below receive the amount standing to my credit in the Employee' Provident Fund , in the event of my Death
PART A (EPF)
Name of the
nominee/nominee's
Address Nominee's
relationship with
the member
Date Of
Birth
Total Amount or
Share of
accumulation in
Provident Fund
to be paid to
each nominee
If the nominee is minor
,name & relationship &
address of the guardian
who may receive the
amount during the
NOMINATION AND DECLARATION FORM
50, CRIG STREET,KAMARHATI,KOLKATA,24 PGS NORTH,WEST BENGAL,700058
50, CRIG STREET,KAMARHATI,KOLKATA,24 PGS NORTH,WEST BENGAL,700058
WB/PRB/0053862/000/0000016
FORM2 (Revised)
GOLAM MURSHID
01-Jan-1969
UNMARRIED
LATE SK MAINUDDIN
MALE
91
,,,,,
50, CRIG
STREET,KAMARHATI,KOLKAT
A,24 PGS NORTH,WEST
BENGAL,700058
01-Jul-1939 34 SHABINA BIBI DEPENDENT MOTHER
,,,,,
50, CRIG
STREET,KAMARHATI,KOLKAT
A,24 PGS NORTH,WEST
BENGAL,700058
11-Sep-1970 33 AMINA KHATOON OTHER
,,,,,
50, CRIG
STREET,KAMARHATI,KOLKAT
A,24 PGS NORTH,WEST
BENGAL,700058
25-Sep-1975 33 HUSNA KHURSHID OTHER
*Cettified that i have no family as defined in para2 (g) of the Employees' Provident Fund Scheme,1952 and
should I acquire a familly hereafter the above nomination should be deemed as cancelled.
*strike out whichever is not applicable Signature or thumb impression of the Subscriber
* Certified that my father / mother is / are dependent upon me.
PART B (EPS)(Para 18)
I hereby furnish below particulars of the members of my family who would be eligible receive
widow/children pension in the event of my death
Sl.
No
1.
Name and Address of the family member Date Of Birth
4
Relationship with
member
5
Address
3
Name
2
1
I hereby nominate the following person for receving the monthly widow pension (admissible under para 16 2(a)(i)(ii) in the
event of my death wihout leaving any eligible family member for receiving pension
**Certified that I have no family as defined in para 2 (vii)of the Employees' Pension Scheme, 1995 and should I acquire a
family hereafter I shall furnish particulars thereon in above form.
Relationship with the member Date Of Birth Name and Address of Nominee
SHABINA BIBI,50, CRIG STREET,KAMARHATI,KOLKATA,24 PGS
NORTH,WEST BENGAL,700058
01-Jul-1939 DEPENDENT MOTHER
Name and address of the Factory/
Establishment or rubber stamp thereof
Designation
Signature of the employer or the other
authorized Officers of the establishment
Place :
Date :
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 got confirmed by him/her.
CERTIFICATE BY EMPLOYER
Signature or thumb impression of the Subscriber *strike out whichever is not applicable
Date :
(For Unexempted/ exempted Establishments)
(Paragraph 33 and 61(1) of the Employees ' Provident Fund Scheme, 1952 &
Paragraph 18of the Employees 'Pension Scheme 1995 )
Declaration and Nomination Form under the Employees' Provident Funds & Employess' Pension Scheme
1. Name 2. Father's / Husband Name
3. Date Of Birth 4. Sex
5. Marital Status 6. Account No.
7. E Mail Address 8. Phone No.
9. Address
Permanent
Temporary
I hereby nominate the person(s)/cancel the nomination made by me previously and nominate the person(s) , mention
below receive the amount standing to my credit in the Employee' Provident Fund , in the event of my Death
PART A (EPF)
Name of the
nominee/nominee's
Address Nominee's
relationship with
the member
Date Of
Birth
Total Amount or
Share of
accumulation in
Provident Fund
to be paid to
each nominee
If the nominee is minor
,name & relationship &
address of the guardian
who may receive the
amount during the
NOMINATION AND DECLARATION FORM
VILL-CHAKRAJUMOLLA,PO-PAILANHAT,PS-BISHNUPUR,,24 PGS SOUTH,WEST BENGAL,700104
VILL-CHAKRAJUMOLLA,PO-PAILANHAT,PS-BISHNUPUR,,24 PGS SOUTH,WEST BENGAL,700104
WB/PRB/0053862/000/0000017
FORM2 (Revised)
JAHAR CHATTERJEE
01-Jul-1960
MARRIED
LATE ASHIT KR CHATTERJEE
MALE
9120005832
,,,,,
VILL-CHAKRAJUMOLLA,PO-P
AILANHAT,PS-BISHNUPUR,,2
4 PGS SOUTH,WEST
BENGAL,700104
01-Jan-1970 50 CHANDA
CHATTERJEE
WIFE
,,,,,
VILL-CHAKRAJUMOLLA,PO-P
AILANHAT,PS-BISHNUPUR,,2
4 PGS SOUTH,WEST
BENGAL,700104
04-Sep-1993 50 RIASHREE
CHATTERJEE
DAUGHTER
*Cettified that i have no family as defined in para2 (g) of the Employees' Provident Fund Scheme,1952 and
should I acquire a familly hereafter the above nomination should be deemed as cancelled.
*strike out whichever is not applicable Signature or thumb impression of the Subscriber
* Certified that my father / mother is / are dependent upon me.
PART B (EPS)(Para 18)
I hereby furnish below particulars of the members of my family who would be eligible receive
widow/children pension in the event of my death
Sl.
No
1.
Name and Address of the family member Date Of Birth
4
Relationship with
member
5
Address
3
Name
2
VILL-CHAKRAJUMOLLA,PO-PAILANHAT
,,24 PGS SOUTH,WEST
1 CHANDA CHATTERJEE 01-Jan-1970 WIFE
VILL-CHAKRAJUMOLLA,PO-PAILANHAT
,,24 PGS SOUTH,,700104
2 CHANJA CHATTERJEE 01-Jan-1970 WIFE
I hereby nominate the following person for receving the monthly widow pension (admissible under para 16 2(a)(i)(ii) in the
event of my death wihout leaving any eligible family member for receiving pension
**Certified that I have no family as defined in para 2 (vii)of the Employees' Pension Scheme, 1995 and should I acquire a
family hereafter I shall furnish particulars thereon in above form.
Relationship with the member Date Of Birth Name and Address of Nominee
Name and address of the Factory/
Establishment or rubber stamp thereof
Designation
Signature of the employer or the other
authorized Officers of the establishment
Place :
Date :
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 got confirmed by him/her.
CERTIFICATE BY EMPLOYER
Signature or thumb impression of the Subscriber *strike out whichever is not applicable
Date :
(For Unexempted/ exempted Establishments)
(Paragraph 33 and 61(1) of the Employees ' Provident Fund Scheme, 1952 &
Paragraph 18of the Employees 'Pension Scheme 1995 )
Declaration and Nomination Form under the Employees' Provident Funds & Employess' Pension Scheme
1. Name 2. Father's / Husband Name
3. Date Of Birth 4. Sex
5. Marital Status 6. Account No.
7. E Mail Address 8. Phone No.
9. Address
Permanent
Temporary
I hereby nominate the person(s)/cancel the nomination made by me previously and nominate the person(s) , mention
below receive the amount standing to my credit in the Employee' Provident Fund , in the event of my Death
PART A (EPF)
Name of the
nominee/nominee's
Address Nominee's
relationship with
the member
Date Of
Birth
Total Amount or
Share of
accumulation in
Provident Fund
to be paid to
each nominee
If the nominee is minor
,name & relationship &
address of the guardian
who may receive the
amount during the
NOMINATION AND DECLARATION FORM
,,,,,
WB/PRB/0053862/000/0000018
FORM2 (Revised)
KOUSIK PATRA
05-Jun-1981
MARRIED
BISWABRATA PATRA
MALE
*Cettified that i have no family as defined in para2 (g) of the Employees' Provident Fund Scheme,1952 and
should I acquire a familly hereafter the above nomination should be deemed as cancelled.
*strike out whichever is not applicable Signature or thumb impression of the Subscriber
* Certified that my father / mother is / are dependent upon me.
PART B (EPS)(Para 18)
I hereby furnish below particulars of the members of my family who would be eligible receive
widow/children pension in the event of my death
Sl.
No
1.
Name and Address of the family member Date Of Birth
4
Relationship with
member
5
Address
3
Name
2
1
I hereby nominate the following person for receving the monthly widow pension (admissible under para 16 2(a)(i)(ii) in the
event of my death wihout leaving any eligible family member for receiving pension
**Certified that I have no family as defined in para 2 (vii)of the Employees' Pension Scheme, 1995 and should I acquire a
family hereafter I shall furnish particulars thereon in above form.
Relationship with the member Date Of Birth Name and Address of Nominee
Name and address of the Factory/
Establishment or rubber stamp thereof
Designation
Signature of the employer or the other
authorized Officers of the establishment
Place :
Date :
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 got confirmed by him/her.
CERTIFICATE BY EMPLOYER
Signature or thumb impression of the Subscriber *strike out whichever is not applicable
Date :
(For Unexempted/ exempted Establishments)
(Paragraph 33 and 61(1) of the Employees ' Provident Fund Scheme, 1952 &
Paragraph 18of the Employees 'Pension Scheme 1995 )
Declaration and Nomination Form under the Employees' Provident Funds & Employess' Pension Scheme
1. Name 2. Father's / Husband Name
3. Date Of Birth 4. Sex
5. Marital Status 6. Account No.
7. E Mail Address 8. Phone No.
9. Address
Permanent
Temporary
I hereby nominate the person(s)/cancel the nomination made by me previously and nominate the person(s) , mention
below receive the amount standing to my credit in the Employee' Provident Fund , in the event of my Death
PART A (EPF)
Name of the
nominee/nominee's
Address Nominee's
relationship with
the member
Date Of
Birth
Total Amount or
Share of
accumulation in
Provident Fund
to be paid to
each nominee
If the nominee is minor
,name & relationship &
address of the guardian
who may receive the
amount during the
NOMINATION AND DECLARATION FORM
,,,,,
WB/PRB/0053862/000/0000019
FORM2 (Revised)
KUNAL MUKHERJEE
05-Jan-1966
MARRIED
SHYAMAPADA MUKHERJEE
MALE
*Cettified that i have no family as defined in para2 (g) of the Employees' Provident Fund Scheme,1952 and
should I acquire a familly hereafter the above nomination should be deemed as cancelled.
*strike out whichever is not applicable Signature or thumb impression of the Subscriber
* Certified that my father / mother is / are dependent upon me.
PART B (EPS)(Para 18)
I hereby furnish below particulars of the members of my family who would be eligible receive
widow/children pension in the event of my death
Sl.
No
1.
Name and Address of the family member Date Of Birth
4
Relationship with
member
5
Address
3
Name
2
1
I hereby nominate the following person for receving the monthly widow pension (admissible under para 16 2(a)(i)(ii) in the
event of my death wihout leaving any eligible family member for receiving pension
**Certified that I have no family as defined in para 2 (vii)of the Employees' Pension Scheme, 1995 and should I acquire a
family hereafter I shall furnish particulars thereon in above form.
Relationship with the member Date Of Birth Name and Address of Nominee
Name and address of the Factory/
Establishment or rubber stamp thereof
Designation
Signature of the employer or the other
authorized Officers of the establishment
Place :
Date :
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 got confirmed by him/her.
CERTIFICATE BY EMPLOYER
Signature or thumb impression of the Subscriber *strike out whichever is not applicable
Date :
(For Unexempted/ exempted Establishments)
(Paragraph 33 and 61(1) of the Employees ' Provident Fund Scheme, 1952 &
Paragraph 18of the Employees 'Pension Scheme 1995 )
Declaration and Nomination Form under the Employees' Provident Funds & Employess' Pension Scheme
1. Name 2. Father's / Husband Name
3. Date Of Birth 4. Sex
5. Marital Status 6. Account No.
7. E Mail Address 8. Phone No.
9. Address
Permanent
Temporary
I hereby nominate the person(s)/cancel the nomination made by me previously and nominate the person(s) , mention
below receive the amount standing to my credit in the Employee' Provident Fund , in the event of my Death
PART A (EPF)
Name of the
nominee/nominee's
Address Nominee's
relationship with
the member
Date Of
Birth
Total Amount or
Share of
accumulation in
Provident Fund
to be paid to
each nominee
If the nominee is minor
,name & relationship &
address of the guardian
who may receive the
amount during the
NOMINATION AND DECLARATION FORM
INDROLOK HOUSING ESTATE-1,BLOCK-A6/3, PAIKPARA,KOLKATA,KOLKATA,WEST BENGAL,700002
INDROLOK HOUSING ESTATE-1,BLOCK-A6/3, PAIKPARA,KOLKATA,KOLKATA,WEST BENGAL,700002
WB/PRB/0053862/000/0000002
FORM2 (Revised)
SUDIPTA BANERJEE
28-Sep-1984
MARRIED
SHYAMAL BANERJEE
FEMALE
8420005831 sudiptasbanerjee@gmail.com
,,,,,
INDROLOK HOUSING
ESTATE-1,BLOCK-A6/3,
PAIKPARA,KOLKATA,KOLKAT
A,WEST BENGAL,700002
04-Oct-1958 50 SHYAMAL BANERJEE DEPENDENT FATHER
,,,,,
INDROLOK HOUSING
ESTATE-1,BLOCK-A6/3,
PAIKPARA,KOLKATA,KOLKAT
A,WEST BENGAL,700002
02-Dec-1963 50 GOPA BANERJEE DEPENDENT MOTHER
*Cettified that i have no family as defined in para2 (g) of the Employees' Provident Fund Scheme,1952 and
should I acquire a familly hereafter the above nomination should be deemed as cancelled.
*strike out whichever is not applicable Signature or thumb impression of the Subscriber
* Certified that my father / mother is / are dependent upon me.
PART B (EPS)(Para 18)
I hereby furnish below particulars of the members of my family who would be eligible receive
widow/children pension in the event of my death
Sl.
No
1.
Name and Address of the family member Date Of Birth
4
Relationship with
member
5
Address
3
Name
2
1
I hereby nominate the following person for receving the monthly widow pension (admissible under para 16 2(a)(i)(ii) in the
event of my death wihout leaving any eligible family member for receiving pension
**Certified that I have no family as defined in para 2 (vii)of the Employees' Pension Scheme, 1995 and should I acquire a
family hereafter I shall furnish particulars thereon in above form.
Relationship with the member Date Of Birth Name and Address of Nominee
GOPA BANERJEE,INDROLOK HOUSING ESTATE-1,BLOCK-A6/3,
PAIKPARA,KOLKATA,KOLKATA,WEST BENGAL,700002
02-Dec-1963 DEPENDENT MOTHER
Name and address of the Factory/
Establishment or rubber stamp thereof
Designation
Signature of the employer or the other
authorized Officers of the establishment
Place :
Date :
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 got confirmed by him/her.
CERTIFICATE BY EMPLOYER
Signature or thumb impression of the Subscriber *strike out whichever is not applicable
Date :
(For Unexempted/ exempted Establishments)
(Paragraph 33 and 61(1) of the Employees ' Provident Fund Scheme, 1952 &
Paragraph 18of the Employees 'Pension Scheme 1995 )
Declaration and Nomination Form under the Employees' Provident Funds & Employess' Pension Scheme
1. Name 2. Father's / Husband Name
3. Date Of Birth 4. Sex
5. Marital Status 6. Account No.
7. E Mail Address 8. Phone No.
9. Address
Permanent
Temporary
I hereby nominate the person(s)/cancel the nomination made by me previously and nominate the person(s) , mention
below receive the amount standing to my credit in the Employee' Provident Fund , in the event of my Death
PART A (EPF)
Name of the
nominee/nominee's
Address Nominee's
relationship with
the member
Date Of
Birth
Total Amount or
Share of
accumulation in
Provident Fund
to be paid to
each nominee
If the nominee is minor
,name & relationship &
address of the guardian
who may receive the
amount during the
NOMINATION AND DECLARATION FORM
VILL-KANAKPUR, PO-NALANDA,PANSKURA,,PURBA MEDNIPUR,WEST BENGAL,721139
VILL-KANAKPUR, PO-NALANDA,PANSKURA,,PURBA MEDNIPUR,WEST BENGAL,721139
WB/PRB/0053862/000/0000020
FORM2 (Revised)
LAKSHMAN DAS
02-Jan-1969
MARRIED
LATE ANIL KUMAR DAS
MALE
9103852437
,,,,,
VILL-KANAKPUR,
PO-NALANDA,PANSKURA,,PU
RBA MEDNIPUR,WEST
BENGAL,721139
01-Jan-1982 50 ASIMA DAS WIFE
,,,,,
VILL-KANAKPUR,
PO-NALANDA,PANSKURA,,PU
RBA MEDNIPUR,WEST
BENGAL,721139
07-Oct-2002 25 ALOKESH DAS SON
,,,,,
VILL-KANAKPUR,
PO-NALANDA,PANSKURA,,PU
RBA MEDNIPUR,WEST
BENGAL,721139
19-Apr-2012 25 ANANYA DAS DAUGHTER
*Cettified that i have no family as defined in para2 (g) of the Employees' Provident Fund Scheme,1952 and
should I acquire a familly hereafter the above nomination should be deemed as cancelled.
*strike out whichever is not applicable Signature or thumb impression of the Subscriber
* Certified that my father / mother is / are dependent upon me.
PART B (EPS)(Para 18)
I hereby furnish below particulars of the members of my family who would be eligible receive
widow/children pension in the event of my death
Sl.
No
1.
Name and Address of the family member Date Of Birth
4
Relationship with
member
5
Address
3
Name
2
VILL-KANAKPUR,
PO-NALANDA,,PURBA
1 ASIMA DAS 01-Jan-1982 WIFE
VILL-KANAKPUR,
PO-NALANDA,,PURBA
2 ALOKESH DAS 07-Oct-2002 SON
VILL-KANAKPUR,
PO-NALANDA,,PURBA
3 ANANYA DAS 19-Apr-2012 DAUGHTER
I hereby nominate the following person for receving the monthly widow pension (admissible under para 16 2(a)(i)(ii) in the
event of my death wihout leaving any eligible family member for receiving pension
**Certified that I have no family as defined in para 2 (vii)of the Employees' Pension Scheme, 1995 and should I acquire a
family hereafter I shall furnish particulars thereon in above form.
Relationship with the member Date Of Birth Name and Address of Nominee
Name and address of the Factory/
Establishment or rubber stamp thereof
Designation
Signature of the employer or the other
authorized Officers of the establishment
Place :
Date :
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 got confirmed by him/her.
CERTIFICATE BY EMPLOYER
Signature or thumb impression of the Subscriber *strike out whichever is not applicable
Date :
(For Unexempted/ exempted Establishments)
(Paragraph 33 and 61(1) of the Employees ' Provident Fund Scheme, 1952 &
Paragraph 18of the Employees 'Pension Scheme 1995 )
Declaration and Nomination Form under the Employees' Provident Funds & Employess' Pension Scheme
1. Name 2. Father's / Husband Name
3. Date Of Birth 4. Sex
5. Marital Status 6. Account No.
7. E Mail Address 8. Phone No.
9. Address
Permanent
Temporary
I hereby nominate the person(s)/cancel the nomination made by me previously and nominate the person(s) , mention
below receive the amount standing to my credit in the Employee' Provident Fund , in the event of my Death
PART A (EPF)
Name of the
nominee/nominee's
Address Nominee's
relationship with
the member
Date Of
Birth
Total Amount or
Share of
accumulation in
Provident Fund
to be paid to
each nominee
If the nominee is minor
,name & relationship &
address of the guardian
who may receive the
amount during the
NOMINATION AND DECLARATION FORM
,,,,,
WB/PRB/0053862/000/0000021
FORM2 (Revised)
LOKNATH SHOW
07-May-1990
MARRIED
BHARAT PRASAD
MALE
*Cettified that i have no family as defined in para2 (g) of the Employees' Provident Fund Scheme,1952 and
should I acquire a familly hereafter the above nomination should be deemed as cancelled.
*strike out whichever is not applicable Signature or thumb impression of the Subscriber
* Certified that my father / mother is / are dependent upon me.
PART B (EPS)(Para 18)
I hereby furnish below particulars of the members of my family who would be eligible receive
widow/children pension in the event of my death
Sl.
No
1.
Name and Address of the family member Date Of Birth
4
Relationship with
member
5
Address
3
Name
2
1
I hereby nominate the following person for receving the monthly widow pension (admissible under para 16 2(a)(i)(ii) in the
event of my death wihout leaving any eligible family member for receiving pension
**Certified that I have no family as defined in para 2 (vii)of the Employees' Pension Scheme, 1995 and should I acquire a
family hereafter I shall furnish particulars thereon in above form.
Relationship with the member Date Of Birth Name and Address of Nominee
Name and address of the Factory/
Establishment or rubber stamp thereof
Designation
Signature of the employer or the other
authorized Officers of the establishment
Place :
Date :
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 got confirmed by him/her.
CERTIFICATE BY EMPLOYER
Signature or thumb impression of the Subscriber *strike out whichever is not applicable
Date :
(For Unexempted/ exempted Establishments)
(Paragraph 33 and 61(1) of the Employees ' Provident Fund Scheme, 1952 &
Paragraph 18of the Employees 'Pension Scheme 1995 )
Declaration and Nomination Form under the Employees' Provident Funds & Employess' Pension Scheme
1. Name 2. Father's / Husband Name
3. Date Of Birth 4. Sex
5. Marital Status 6. Account No.
7. E Mail Address 8. Phone No.
9. Address
Permanent
Temporary
I hereby nominate the person(s)/cancel the nomination made by me previously and nominate the person(s) , mention
below receive the amount standing to my credit in the Employee' Provident Fund , in the event of my Death
PART A (EPF)
Name of the
nominee/nominee's
Address Nominee's
relationship with
the member
Date Of
Birth
Total Amount or
Share of
accumulation in
Provident Fund
to be paid to
each nominee
If the nominee is minor
,name & relationship &
address of the guardian
who may receive the
amount during the
NOMINATION AND DECLARATION FORM
,,,,,
WB/PRB/0053862/000/0000022
FORM2 (Revised)
MIHIR BISWAS
02-Feb-1986
MARRIED
TIMIR BARAN BISWAS
MALE
*Cettified that i have no family as defined in para2 (g) of the Employees' Provident Fund Scheme,1952 and
should I acquire a familly hereafter the above nomination should be deemed as cancelled.
*strike out whichever is not applicable Signature or thumb impression of the Subscriber
* Certified that my father / mother is / are dependent upon me.
PART B (EPS)(Para 18)
I hereby furnish below particulars of the members of my family who would be eligible receive
widow/children pension in the event of my death
Sl.
No
1.
Name and Address of the family member Date Of Birth
4
Relationship with
member
5
Address
3
Name
2
1
I hereby nominate the following person for receving the monthly widow pension (admissible under para 16 2(a)(i)(ii) in the
event of my death wihout leaving any eligible family member for receiving pension
**Certified that I have no family as defined in para 2 (vii)of the Employees' Pension Scheme, 1995 and should I acquire a
family hereafter I shall furnish particulars thereon in above form.
Relationship with the member Date Of Birth Name and Address of Nominee
Name and address of the Factory/
Establishment or rubber stamp thereof
Designation
Signature of the employer or the other
authorized Officers of the establishment
Place :
Date :
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 got confirmed by him/her.
CERTIFICATE BY EMPLOYER
Signature or thumb impression of the Subscriber *strike out whichever is not applicable
Date :
(For Unexempted/ exempted Establishments)
(Paragraph 33 and 61(1) of the Employees ' Provident Fund Scheme, 1952 &
Paragraph 18of the Employees 'Pension Scheme 1995 )
Declaration and Nomination Form under the Employees' Provident Funds & Employess' Pension Scheme
1. Name 2. Father's / Husband Name
3. Date Of Birth 4. Sex
5. Marital Status 6. Account No.
7. E Mail Address 8. Phone No.
9. Address
Permanent
Temporary
I hereby nominate the person(s)/cancel the nomination made by me previously and nominate the person(s) , mention
below receive the amount standing to my credit in the Employee' Provident Fund , in the event of my Death
PART A (EPF)
Name of the
nominee/nominee's
Address Nominee's
relationship with
the member
Date Of
Birth
Total Amount or
Share of
accumulation in
Provident Fund
to be paid to
each nominee
If the nominee is minor
,name & relationship &
address of the guardian
who may receive the
amount during the
NOMINATION AND DECLARATION FORM
,,,,,
WB/PRB/0053862/000/0000023
FORM2 (Revised)
NILADARI BHATTACHARYA
27-Nov-1986
MARRIED
BACHASPATI BHATTACHARYA
MALE
91
*Cettified that i have no family as defined in para2 (g) of the Employees' Provident Fund Scheme,1952 and
should I acquire a familly hereafter the above nomination should be deemed as cancelled.
*strike out whichever is not applicable Signature or thumb impression of the Subscriber
* Certified that my father / mother is / are dependent upon me.
PART B (EPS)(Para 18)
I hereby furnish below particulars of the members of my family who would be eligible receive
widow/children pension in the event of my death
Sl.
No
1.
Name and Address of the family member Date Of Birth
4
Relationship with
member
5
Address
3
Name
2
1
I hereby nominate the following person for receving the monthly widow pension (admissible under para 16 2(a)(i)(ii) in the
event of my death wihout leaving any eligible family member for receiving pension
**Certified that I have no family as defined in para 2 (vii)of the Employees' Pension Scheme, 1995 and should I acquire a
family hereafter I shall furnish particulars thereon in above form.
Relationship with the member Date Of Birth Name and Address of Nominee
Name and address of the Factory/
Establishment or rubber stamp thereof
Designation
Signature of the employer or the other
authorized Officers of the establishment
Place :
Date :
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 got confirmed by him/her.
CERTIFICATE BY EMPLOYER
Signature or thumb impression of the Subscriber *strike out whichever is not applicable
Date :
(For Unexempted/ exempted Establishments)
(Paragraph 33 and 61(1) of the Employees ' Provident Fund Scheme, 1952 &
Paragraph 18of the Employees 'Pension Scheme 1995 )
Declaration and Nomination Form under the Employees' Provident Funds & Employess' Pension Scheme
1. Name 2. Father's / Husband Name
3. Date Of Birth 4. Sex
5. Marital Status 6. Account No.
7. E Mail Address 8. Phone No.
9. Address
Permanent
Temporary
I hereby nominate the person(s)/cancel the nomination made by me previously and nominate the person(s) , mention
below receive the amount standing to my credit in the Employee' Provident Fund , in the event of my Death
PART A (EPF)
Name of the
nominee/nominee's
Address Nominee's
relationship with
the member
Date Of
Birth
Total Amount or
Share of
accumulation in
Provident Fund
to be paid to
each nominee
If the nominee is minor
,name & relationship &
address of the guardian
who may receive the
amount during the
NOMINATION AND DECLARATION FORM
10, DR P K BANERJEE ROAD,,,HOWRAH,WEST BENGAL,711101
10, DR P K BANERJEE ROAD,,,HOWRAH,WEST BENGAL,711101
WB/PRB/0053862/000/0000024
FORM2 (Revised)
PIYUSH KUMAR RAI
15-Jul-1989
UNMARRIED
SHIV SANKAR RAI
MALE
8981361784 raipiyush123@gmail.com
,,,,,
10, DR P K BANERJEE
ROAD,,,HOWRAH,WEST
BENGAL,711101
01-Mar-1954 100 MANKI DEVI DEPENDENT MOTHER
*Cettified that i have no family as defined in para2 (g) of the Employees' Provident Fund Scheme,1952 and
should I acquire a familly hereafter the above nomination should be deemed as cancelled.
*strike out whichever is not applicable Signature or thumb impression of the Subscriber
* Certified that my father / mother is / are dependent upon me.
PART B (EPS)(Para 18)
I hereby furnish below particulars of the members of my family who would be eligible receive
widow/children pension in the event of my death
Sl.
No
1.
Name and Address of the family member Date Of Birth
4
Relationship with
member
5
Address
3
Name
2
1
I hereby nominate the following person for receving the monthly widow pension (admissible under para 16 2(a)(i)(ii) in the
event of my death wihout leaving any eligible family member for receiving pension
**Certified that I have no family as defined in para 2 (vii)of the Employees' Pension Scheme, 1995 and should I acquire a
family hereafter I shall furnish particulars thereon in above form.
Relationship with the member Date Of Birth Name and Address of Nominee
MANKI DEVI,10, DR P K BANERJEE ROAD,,,HOWRAH,WEST
BENGAL,711101
01-Mar-1954 DEPENDENT MOTHER
Name and address of the Factory/
Establishment or rubber stamp thereof
Designation
Signature of the employer or the other
authorized Officers of the establishment
Place :
Date :
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 got confirmed by him/her.
CERTIFICATE BY EMPLOYER
Signature or thumb impression of the Subscriber *strike out whichever is not applicable
Date :
(For Unexempted/ exempted Establishments)
(Paragraph 33 and 61(1) of the Employees ' Provident Fund Scheme, 1952 &
Paragraph 18of the Employees 'Pension Scheme 1995 )
Declaration and Nomination Form under the Employees' Provident Funds & Employess' Pension Scheme
1. Name 2. Father's / Husband Name
3. Date Of Birth 4. Sex
5. Marital Status 6. Account No.
7. E Mail Address 8. Phone No.
9. Address
Permanent
Temporary
I hereby nominate the person(s)/cancel the nomination made by me previously and nominate the person(s) , mention
below receive the amount standing to my credit in the Employee' Provident Fund , in the event of my Death
PART A (EPF)
Name of the
nominee/nominee's
Address Nominee's
relationship with
the member
Date Of
Birth
Total Amount or
Share of
accumulation in
Provident Fund
to be paid to
each nominee
If the nominee is minor
,name & relationship &
address of the guardian
who may receive the
amount during the
NOMINATION AND DECLARATION FORM
IDEAL ASSOCIATION BLOCK A/8,VIP ROAD, KOLKATA,KOLKATA,,WEST BENGAL,700054
IDEAL ASSOCIATION BLOCK A/8,VIP ROAD, KOLKATA,KOLKATA,,WEST BENGAL,700054
WB/PRB/0053862/000/0000025
FORM2 (Revised)
RAJA ROYCHOWDHURY
11-Feb-1967
UNMARRIED
LATE RANJIT KUMAR ROYCHOWDHURY
MALE
9131472235
,,,,,
IDEAL ASSOCIATION BLOCK
A/8,VIP ROAD,
KOLKATA,KOLKATA,,WEST
BENGAL,700054
08-May-1972 100 PRONOB
ROYCHOWDHURY
OTHER
*Cettified that i have no family as defined in para2 (g) of the Employees' Provident Fund Scheme,1952 and
should I acquire a familly hereafter the above nomination should be deemed as cancelled.
*strike out whichever is not applicable Signature or thumb impression of the Subscriber
* Certified that my father / mother is / are dependent upon me.
PART B (EPS)(Para 18)
I hereby furnish below particulars of the members of my family who would be eligible receive
widow/children pension in the event of my death
Sl.
No
1.
Name and Address of the family member Date Of Birth
4
Relationship with
member
5
Address
3
Name
2
1
I hereby nominate the following person for receving the monthly widow pension (admissible under para 16 2(a)(i)(ii) in the
event of my death wihout leaving any eligible family member for receiving pension
**Certified that I have no family as defined in para 2 (vii)of the Employees' Pension Scheme, 1995 and should I acquire a
family hereafter I shall furnish particulars thereon in above form.
Relationship with the member Date Of Birth Name and Address of Nominee
PRONOB ROYCHOWDHURY,IDEAL ASSOCIATION BLOCK A/8,VIP
ROAD, KOLKATA,KOLKATA,,WEST BENGAL,700054
08-May-1972 OTHER
Name and address of the Factory/
Establishment or rubber stamp thereof
Designation
Signature of the employer or the other
authorized Officers of the establishment
Place :
Date :
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 got confirmed by him/her.
CERTIFICATE BY EMPLOYER
Signature or thumb impression of the Subscriber *strike out whichever is not applicable
Date :
(For Unexempted/ exempted Establishments)
(Paragraph 33 and 61(1) of the Employees ' Provident Fund Scheme, 1952 &
Paragraph 18of the Employees 'Pension Scheme 1995 )
Declaration and Nomination Form under the Employees' Provident Funds & Employess' Pension Scheme
1. Name 2. Father's / Husband Name
3. Date Of Birth 4. Sex
5. Marital Status 6. Account No.
7. E Mail Address 8. Phone No.
9. Address
Permanent
Temporary
I hereby nominate the person(s)/cancel the nomination made by me previously and nominate the person(s) , mention
below receive the amount standing to my credit in the Employee' Provident Fund , in the event of my Death
PART A (EPF)
Name of the
nominee/nominee's
Address Nominee's
relationship with
the member
Date Of
Birth
Total Amount or
Share of
accumulation in
Provident Fund
to be paid to
each nominee
If the nominee is minor
,name & relationship &
address of the guardian
who may receive the
amount during the
NOMINATION AND DECLARATION FORM
168/4 BELEGHATA MAIN ROAD,,KOLKATA,KOLKATA,WEST BENGAL,700085
168/4 BELEGHATA MAIN ROAD,,KOLKATA,KOLKATA,WEST BENGAL,700085
WB/PRB/0053862/000/0000026
FORM2 (Revised)
SANJIB GUHA ROY
01-Apr-1970
UNMARRIED
LATE KHAGENDRA NATH GUHA ROY
MALE
91
,,,,,
168/4 BELEGHATA MAIN
ROAD,,KOLKATA,KOLKATA,W
EST BENGAL,700085
17-Sep-1959 100 DEBJANI GUHA ROY OTHER
*Cettified that i have no family as defined in para2 (g) of the Employees' Provident Fund Scheme,1952 and
should I acquire a familly hereafter the above nomination should be deemed as cancelled.
*strike out whichever is not applicable Signature or thumb impression of the Subscriber
* Certified that my father / mother is / are dependent upon me.
PART B (EPS)(Para 18)
I hereby furnish below particulars of the members of my family who would be eligible receive
widow/children pension in the event of my death
Sl.
No
1.
Name and Address of the family member Date Of Birth
4
Relationship with
member
5
Address
3
Name
2
1
I hereby nominate the following person for receving the monthly widow pension (admissible under para 16 2(a)(i)(ii) in the
event of my death wihout leaving any eligible family member for receiving pension
**Certified that I have no family as defined in para 2 (vii)of the Employees' Pension Scheme, 1995 and should I acquire a
family hereafter I shall furnish particulars thereon in above form.
Relationship with the member Date Of Birth Name and Address of Nominee
DEBJANI GUHA ROY,168/4 BELEGHATA MAIN
ROAD,,KOLKATA,KOLKATA,WEST BENGAL,700085
17-Sep-1959 OTHER
Name and address of the Factory/
Establishment or rubber stamp thereof
Designation
Signature of the employer or the other
authorized Officers of the establishment
Place :
Date :
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 got confirmed by him/her.
CERTIFICATE BY EMPLOYER
Signature or thumb impression of the Subscriber *strike out whichever is not applicable
Date :
(For Unexempted/ exempted Establishments)
(Paragraph 33 and 61(1) of the Employees ' Provident Fund Scheme, 1952 &
Paragraph 18of the Employees 'Pension Scheme 1995 )
Declaration and Nomination Form under the Employees' Provident Funds & Employess' Pension Scheme
1. Name 2. Father's / Husband Name
3. Date Of Birth 4. Sex
5. Marital Status 6. Account No.
7. E Mail Address 8. Phone No.
9. Address
Permanent
Temporary
I hereby nominate the person(s)/cancel the nomination made by me previously and nominate the person(s) , mention
below receive the amount standing to my credit in the Employee' Provident Fund , in the event of my Death
PART A (EPF)
Name of the
nominee/nominee's
Address Nominee's
relationship with
the member
Date Of
Birth
Total Amount or
Share of
accumulation in
Provident Fund
to be paid to
each nominee
If the nominee is minor
,name & relationship &
address of the guardian
who may receive the
amount during the
NOMINATION AND DECLARATION FORM
,,,,,
WB/PRB/0053862/000/0000027
FORM2 (Revised)
SARAN SARKAR
23-Jun-1967
MARRIED
SUDHANSHU SEKHAR SARKAR
MALE
*Cettified that i have no family as defined in para2 (g) of the Employees' Provident Fund Scheme,1952 and
should I acquire a familly hereafter the above nomination should be deemed as cancelled.
*strike out whichever is not applicable Signature or thumb impression of the Subscriber
* Certified that my father / mother is / are dependent upon me.
PART B (EPS)(Para 18)
I hereby furnish below particulars of the members of my family who would be eligible receive
widow/children pension in the event of my death
Sl.
No
1.
Name and Address of the family member Date Of Birth
4
Relationship with
member
5
Address
3
Name
2
1
I hereby nominate the following person for receving the monthly widow pension (admissible under para 16 2(a)(i)(ii) in the
event of my death wihout leaving any eligible family member for receiving pension
**Certified that I have no family as defined in para 2 (vii)of the Employees' Pension Scheme, 1995 and should I acquire a
family hereafter I shall furnish particulars thereon in above form.
Relationship with the member Date Of Birth Name and Address of Nominee
Name and address of the Factory/
Establishment or rubber stamp thereof
Designation
Signature of the employer or the other
authorized Officers of the establishment
Place :
Date :
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 got confirmed by him/her.
CERTIFICATE BY EMPLOYER
Signature or thumb impression of the Subscriber *strike out whichever is not applicable
Date :
(For Unexempted/ exempted Establishments)
(Paragraph 33 and 61(1) of the Employees ' Provident Fund Scheme, 1952 &
Paragraph 18of the Employees 'Pension Scheme 1995 )
Declaration and Nomination Form under the Employees' Provident Funds & Employess' Pension Scheme
1. Name 2. Father's / Husband Name
3. Date Of Birth 4. Sex
5. Marital Status 6. Account No.
7. E Mail Address 8. Phone No.
9. Address
Permanent
Temporary
I hereby nominate the person(s)/cancel the nomination made by me previously and nominate the person(s) , mention
below receive the amount standing to my credit in the Employee' Provident Fund , in the event of my Death
PART A (EPF)
Name of the
nominee/nominee's
Address Nominee's
relationship with
the member
Date Of
Birth
Total Amount or
Share of
accumulation in
Provident Fund
to be paid to
each nominee
If the nominee is minor
,name & relationship &
address of the guardian
who may receive the
amount during the
NOMINATION AND DECLARATION FORM
ANTILA,BAGNAN,HOWRAH,HOWRAH,WEST BENGAL,
ANTILA,BAGNAN,HOWRAH,HOWRAH,WEST BENGAL,
WB/PRB/0053862/000/0000028
FORM2 (Revised)
SEKHAR CHANDRA BERA
18-Jan-1978
UNMARRIED
DULAL CHANDRA BERA
MALE
,,,,,
ANTILA,BAGNAN,HOWRAH,H
OWRAH,WEST BENGAL,
05-Feb-1945 50 DULAL CH BERA DEPENDENT FATHER
,,,,,
ANTILA,BAGNAN,HOWRAH,H
OWRAH,WEST BENGAL,
10-Jul-1957 50 SABITA BERA DEPENDENT MOTHER
*Cettified that i have no family as defined in para2 (g) of the Employees' Provident Fund Scheme,1952 and
should I acquire a familly hereafter the above nomination should be deemed as cancelled.
*strike out whichever is not applicable Signature or thumb impression of the Subscriber
* Certified that my father / mother is / are dependent upon me.
PART B (EPS)(Para 18)
I hereby furnish below particulars of the members of my family who would be eligible receive
widow/children pension in the event of my death
Sl.
No
1.
Name and Address of the family member Date Of Birth
4
Relationship with
member
5
Address
3
Name
2
1
I hereby nominate the following person for receving the monthly widow pension (admissible under para 16 2(a)(i)(ii) in the
event of my death wihout leaving any eligible family member for receiving pension
**Certified that I have no family as defined in para 2 (vii)of the Employees' Pension Scheme, 1995 and should I acquire a
family hereafter I shall furnish particulars thereon in above form.
Relationship with the member Date Of Birth Name and Address of Nominee
SABITA BERA,ANTILA,BAGNAN,HOWRAH,HOWRAH,WEST BENGAL, 10-Jul-1957 DEPENDENT MOTHER
Name and address of the Factory/
Establishment or rubber stamp thereof
Designation
Signature of the employer or the other
authorized Officers of the establishment
Place :
Date :
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 got confirmed by him/her.
CERTIFICATE BY EMPLOYER
Signature or thumb impression of the Subscriber *strike out whichever is not applicable
Date :
(For Unexempted/ exempted Establishments)
(Paragraph 33 and 61(1) of the Employees ' Provident Fund Scheme, 1952 &
Paragraph 18of the Employees 'Pension Scheme 1995 )
Declaration and Nomination Form under the Employees' Provident Funds & Employess' Pension Scheme
1. Name 2. Father's / Husband Name
3. Date Of Birth 4. Sex
5. Marital Status 6. Account No.
7. E Mail Address 8. Phone No.
9. Address
Permanent
Temporary
I hereby nominate the person(s)/cancel the nomination made by me previously and nominate the person(s) , mention
below receive the amount standing to my credit in the Employee' Provident Fund , in the event of my Death
PART A (EPF)
Name of the
nominee/nominee's
Address Nominee's
relationship with
the member
Date Of
Birth
Total Amount or
Share of
accumulation in
Provident Fund
to be paid to
each nominee
If the nominee is minor
,name & relationship &
address of the guardian
who may receive the
amount during the
NOMINATION AND DECLARATION FORM
KERANICHATY,BHADUTALA,KOTWALI, MIDNAPUR,PACHIM MEDNIPUR,WEST BENGAL,721129
KERANICHATY,BHADUTALA,KOTWALI, MIDNAPUR,PACHIM MEDNIPUR,WEST BENGAL,721129
WB/PRB/0053862/000/0000029
FORM2 (Revised)
SANTANU GHOSH
06-Feb-1987
MARRIED
ACHINTYA KR GHOSH
MALE
91 san.ghosh2008@gmail.com
,,,,,
KERANICHATY,BHADUTALA,
KOTWALI,
MIDNAPUR,PACHIM
MEDNIPUR,WEST
BENGAL,721129
20-Mar-1988 100 NANDITA PAL GHOSH WIFE
*Cettified that i have no family as defined in para2 (g) of the Employees' Provident Fund Scheme,1952 and
should I acquire a familly hereafter the above nomination should be deemed as cancelled.
*strike out whichever is not applicable Signature or thumb impression of the Subscriber
* Certified that my father / mother is / are dependent upon me.
PART B (EPS)(Para 18)
I hereby furnish below particulars of the members of my family who would be eligible receive
widow/children pension in the event of my death
Sl.
No
1.
Name and Address of the family member Date Of Birth
4
Relationship with
member
5
Address
3
Name
2
KERANICHATY,KOTWALI,
MIDNAPUR,PACHIM
1 NANDITA PAL GHOSH 20-Mar-1988 WIFE
I hereby nominate the following person for receving the monthly widow pension (admissible under para 16 2(a)(i)(ii) in the
event of my death wihout leaving any eligible family member for receiving pension
**Certified that I have no family as defined in para 2 (vii)of the Employees' Pension Scheme, 1995 and should I acquire a
family hereafter I shall furnish particulars thereon in above form.
Relationship with the member Date Of Birth Name and Address of Nominee
Name and address of the Factory/
Establishment or rubber stamp thereof
Designation
Signature of the employer or the other
authorized Officers of the establishment
Place :
Date :
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 got confirmed by him/her.
CERTIFICATE BY EMPLOYER
Signature or thumb impression of the Subscriber *strike out whichever is not applicable
Date :
(For Unexempted/ exempted Establishments)
(Paragraph 33 and 61(1) of the Employees ' Provident Fund Scheme, 1952 &
Paragraph 18of the Employees 'Pension Scheme 1995 )
Declaration and Nomination Form under the Employees' Provident Funds & Employess' Pension Scheme
1. Name 2. Father's / Husband Name
3. Date Of Birth 4. Sex
5. Marital Status 6. Account No.
7. E Mail Address 8. Phone No.
9. Address
Permanent
Temporary
I hereby nominate the person(s)/cancel the nomination made by me previously and nominate the person(s) , mention
below receive the amount standing to my credit in the Employee' Provident Fund , in the event of my Death
PART A (EPF)
Name of the
nominee/nominee's
Address Nominee's
relationship with
the member
Date Of
Birth
Total Amount or
Share of
accumulation in
Provident Fund
to be paid to
each nominee
If the nominee is minor
,name & relationship &
address of the guardian
who may receive the
amount during the
NOMINATION AND DECLARATION FORM
39 B BELTALA ROAD,,KOLKATA,KOLKATA,WEST BENGAL,700020
39 B BELTALA ROAD,,KOLKATA,KOLKATA,WEST BENGAL,700020
WB/PRB/0053862/000/0000003
FORM2 (Revised)
ASWINI MAITY
13-Jan-1993
UNMARRIED
LATE SANTOSH MAITY
MALE
91
,,,,,
39 B BELTALA
ROAD,,KOLKATA,KOLKATA,W
EST BENGAL,700020
02-Apr-1955 50 USHA MAITY DEPENDENT MOTHER
,,,,,
39 B BELTALA
ROAD,,KOLKATA,KOLKATA,W
EST BENGAL,700020
04-Feb-1995 50 SUJATA MAITY OTHER
*Cettified that i have no family as defined in para2 (g) of the Employees' Provident Fund Scheme,1952 and
should I acquire a familly hereafter the above nomination should be deemed as cancelled.
*strike out whichever is not applicable Signature or thumb impression of the Subscriber
* Certified that my father / mother is / are dependent upon me.
PART B (EPS)(Para 18)
I hereby furnish below particulars of the members of my family who would be eligible receive
widow/children pension in the event of my death
Sl.
No
1.
Name and Address of the family member Date Of Birth
4
Relationship with
member
5
Address
3
Name
2
1
I hereby nominate the following person for receving the monthly widow pension (admissible under para 16 2(a)(i)(ii) in the
event of my death wihout leaving any eligible family member for receiving pension
**Certified that I have no family as defined in para 2 (vii)of the Employees' Pension Scheme, 1995 and should I acquire a
family hereafter I shall furnish particulars thereon in above form.
Relationship with the member Date Of Birth Name and Address of Nominee
USHA MAITY,39 B BELTALA ROAD,,KOLKATA,KOLKATA,WEST
BENGAL,700020
02-Apr-1955 DEPENDENT MOTHER
Name and address of the Factory/
Establishment or rubber stamp thereof
Designation
Signature of the employer or the other
authorized Officers of the establishment
Place :
Date :
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 got confirmed by him/her.
CERTIFICATE BY EMPLOYER
Signature or thumb impression of the Subscriber *strike out whichever is not applicable
Date :
(For Unexempted/ exempted Establishments)
(Paragraph 33 and 61(1) of the Employees ' Provident Fund Scheme, 1952 &
Paragraph 18of the Employees 'Pension Scheme 1995 )
Declaration and Nomination Form under the Employees' Provident Funds & Employess' Pension Scheme
1. Name 2. Father's / Husband Name
3. Date Of Birth 4. Sex
5. Marital Status 6. Account No.
7. E Mail Address 8. Phone No.
9. Address
Permanent
Temporary
I hereby nominate the person(s)/cancel the nomination made by me previously and nominate the person(s) , mention
below receive the amount standing to my credit in the Employee' Provident Fund , in the event of my Death
PART A (EPF)
Name of the
nominee/nominee's
Address Nominee's
relationship with
the member
Date Of
Birth
Total Amount or
Share of
accumulation in
Provident Fund
to be paid to
each nominee
If the nominee is minor
,name & relationship &
address of the guardian
who may receive the
amount during the
NOMINATION AND DECLARATION FORM
30, KHELATBABU LANE,,KOLKATA,,WEST BENGAL,700037
99, COSSIPORE ROAD,,KOLKATA,KOLKATA,WEST BENGAL,700002
WB/PRB/0053862/000/0000030
FORM2 (Revised)
SK.SAHID
02-Jan-1977
MARRIED
SK MAJID
MALE
9748786502
,,,,,
30, KHELATBABU
LANE,,KOLKATA,,WEST
BENGAL,700037
09-Oct-1945 25 SK MAZID DEPENDENT FATHER
,,,,,
30, KHELATBABU
LANE,,KOLKATA,,WEST
BENGAL,700037
05-Jun-1962 25 HASINA BIBI DEPENDENT MOTHER
,,,,,
30, KHELATBABU
LANE,,KOLKATA,,WEST
BENGAL,700037
01-Jan-1984 25 TASNIM BIBI WIFE
,,,,,
30, KHELATBABU
LANE,,KOLKATA,,WEST
BENGAL,700037
21-Apr-2014 25 MD MISBAH SON
*Cettified that i have no family as defined in para2 (g) of the Employees' Provident Fund Scheme,1952 and
should I acquire a familly hereafter the above nomination should be deemed as cancelled.
*strike out whichever is not applicable Signature or thumb impression of the Subscriber
* Certified that my father / mother is / are dependent upon me.
PART B (EPS)(Para 18)
I hereby furnish below particulars of the members of my family who would be eligible receive
widow/children pension in the event of my death
Sl.
No
1.
Name and Address of the family member Date Of Birth
4
Relationship with
member
5
Address
3
Name
2
30, KHELATBABU
LANE,KOLKATA,,,700037
1 TASNIM BIBI 01-Jan-1984 WIFE
30, KHELATBABU
LANE,KOLKATA,,WEST
2 MD MISBAH 21-Apr-2014 SON
I hereby nominate the following person for receving the monthly widow pension (admissible under para 16 2(a)(i)(ii) in the
event of my death wihout leaving any eligible family member for receiving pension
**Certified that I have no family as defined in para 2 (vii)of the Employees' Pension Scheme, 1995 and should I acquire a
family hereafter I shall furnish particulars thereon in above form.
Relationship with the member Date Of Birth Name and Address of Nominee
Name and address of the Factory/
Establishment or rubber stamp thereof
Designation
Signature of the employer or the other
authorized Officers of the establishment
Place :
Date :
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 got confirmed by him/her.
CERTIFICATE BY EMPLOYER
Signature or thumb impression of the Subscriber *strike out whichever is not applicable
Date :
(For Unexempted/ exempted Establishments)
(Paragraph 33 and 61(1) of the Employees ' Provident Fund Scheme, 1952 &
Paragraph 18of the Employees 'Pension Scheme 1995 )
Declaration and Nomination Form under the Employees' Provident Funds & Employess' Pension Scheme
1. Name 2. Father's / Husband Name
3. Date Of Birth 4. Sex
5. Marital Status 6. Account No.
7. E Mail Address 8. Phone No.
9. Address
Permanent
Temporary
I hereby nominate the person(s)/cancel the nomination made by me previously and nominate the person(s) , mention
below receive the amount standing to my credit in the Employee' Provident Fund , in the event of my Death
PART A (EPF)
Name of the
nominee/nominee's
Address Nominee's
relationship with
the member
Date Of
Birth
Total Amount or
Share of
accumulation in
Provident Fund
to be paid to
each nominee
If the nominee is minor
,name & relationship &
address of the guardian
who may receive the
amount during the
NOMINATION AND DECLARATION FORM
20 N C PAKRISHI LANE,RISHRA,,HOOGHLY,WEST BENGAL,712248
20 N C PAKRISHI LANE,RISHRA,,HOOGHLY,WEST BENGAL,712248
WB/PRB/0053862/000/0000031
FORM2 (Revised)
SRIKANTA NAG
18-Aug-1967
MARRIED
LATE BISWANATH NAG
MALE
91
,,,,,
20 N C PAKRISHI
LANE,RISHRA,,HOOGHLY,WE
ST BENGAL,712248
01-Jan-1970 50 ASHOKA NAG WIFE
,,,,,
20 N C PAKRISHI
LANE,RISHRA,,HOOGHLY,WE
ST BENGAL,712248
30-Jun-1996 50 ADRIJA NAG DAUGHTER
*Cettified that i have no family as defined in para2 (g) of the Employees' Provident Fund Scheme,1952 and
should I acquire a familly hereafter the above nomination should be deemed as cancelled.
*strike out whichever is not applicable Signature or thumb impression of the Subscriber
* Certified that my father / mother is / are dependent upon me.
PART B (EPS)(Para 18)
I hereby furnish below particulars of the members of my family who would be eligible receive
widow/children pension in the event of my death
Sl.
No
1.
Name and Address of the family member Date Of Birth
4
Relationship with
member
5
Address
3
Name
2
20 N C PAKRISHI
LANE,,HOOGHLY,,712248
1 ASHOKA NAG 01-Jan-1970 WIFE
20 N C PAKRISHI
LANE,,HOOGHLY,WEST
2 ADRIJA NAG 30-Jun-1996 DAUGHTER
I hereby nominate the following person for receving the monthly widow pension (admissible under para 16 2(a)(i)(ii) in the
event of my death wihout leaving any eligible family member for receiving pension
**Certified that I have no family as defined in para 2 (vii)of the Employees' Pension Scheme, 1995 and should I acquire a
family hereafter I shall furnish particulars thereon in above form.
Relationship with the member Date Of Birth Name and Address of Nominee
Name and address of the Factory/
Establishment or rubber stamp thereof
Designation
Signature of the employer or the other
authorized Officers of the establishment
Place :
Date :
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 got confirmed by him/her.
CERTIFICATE BY EMPLOYER
Signature or thumb impression of the Subscriber *strike out whichever is not applicable
Date :
(For Unexempted/ exempted Establishments)
(Paragraph 33 and 61(1) of the Employees ' Provident Fund Scheme, 1952 &
Paragraph 18of the Employees 'Pension Scheme 1995 )
Declaration and Nomination Form under the Employees' Provident Funds & Employess' Pension Scheme
1. Name 2. Father's / Husband Name
3. Date Of Birth 4. Sex
5. Marital Status 6. Account No.
7. E Mail Address 8. Phone No.
9. Address
Permanent
Temporary
I hereby nominate the person(s)/cancel the nomination made by me previously and nominate the person(s) , mention
below receive the amount standing to my credit in the Employee' Provident Fund , in the event of my Death
PART A (EPF)
Name of the
nominee/nominee's
Address Nominee's
relationship with
the member
Date Of
Birth
Total Amount or
Share of
accumulation in
Provident Fund
to be paid to
each nominee
If the nominee is minor
,name & relationship &
address of the guardian
who may receive the
amount during the
NOMINATION AND DECLARATION FORM
,,,,,
WB/PRB/0053862/000/0000032
FORM2 (Revised)
SRIMANTA LAHA
06-Sep-1962
MARRIED
SANTOSH KUMAR LAHA
MALE
*Cettified that i have no family as defined in para2 (g) of the Employees' Provident Fund Scheme,1952 and
should I acquire a familly hereafter the above nomination should be deemed as cancelled.
*strike out whichever is not applicable Signature or thumb impression of the Subscriber
* Certified that my father / mother is / are dependent upon me.
PART B (EPS)(Para 18)
I hereby furnish below particulars of the members of my family who would be eligible receive
widow/children pension in the event of my death
Sl.
No
1.
Name and Address of the family member Date Of Birth
4
Relationship with
member
5
Address
3
Name
2
1
I hereby nominate the following person for receving the monthly widow pension (admissible under para 16 2(a)(i)(ii) in the
event of my death wihout leaving any eligible family member for receiving pension
**Certified that I have no family as defined in para 2 (vii)of the Employees' Pension Scheme, 1995 and should I acquire a
family hereafter I shall furnish particulars thereon in above form.
Relationship with the member Date Of Birth Name and Address of Nominee
Name and address of the Factory/
Establishment or rubber stamp thereof
Designation
Signature of the employer or the other
authorized Officers of the establishment
Place :
Date :
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 got confirmed by him/her.
CERTIFICATE BY EMPLOYER
Signature or thumb impression of the Subscriber *strike out whichever is not applicable
Date :
(For Unexempted/ exempted Establishments)
(Paragraph 33 and 61(1) of the Employees ' Provident Fund Scheme, 1952 &
Paragraph 18of the Employees 'Pension Scheme 1995 )
Declaration and Nomination Form under the Employees' Provident Funds & Employess' Pension Scheme
1. Name 2. Father's / Husband Name
3. Date Of Birth 4. Sex
5. Marital Status 6. Account No.
7. E Mail Address 8. Phone No.
9. Address
Permanent
Temporary
I hereby nominate the person(s)/cancel the nomination made by me previously and nominate the person(s) , mention
below receive the amount standing to my credit in the Employee' Provident Fund , in the event of my Death
PART A (EPF)
Name of the
nominee/nominee's
Address Nominee's
relationship with
the member
Date Of
Birth
Total Amount or
Share of
accumulation in
Provident Fund
to be paid to
each nominee
If the nominee is minor
,name & relationship &
address of the guardian
who may receive the
amount during the
NOMINATION AND DECLARATION FORM
14, BISWAS PARA LANE,KOLKATA,KOLKATA,,WEST BENGAL,700033
14, BISWAS PARA LANE,KOLKATA,KOLKATA,,WEST BENGAL,700033
WB/PRB/0053862/000/0000033
FORM2 (Revised)
SUBHASHIS DASGUPTA
17-Apr-1967
MARRIED
LATE KAMALESH DASGUPTA
MALE
91
,,,,,
14, BISWAS PARA
LANE,KOLKATA,KOLKATA,,W
EST BENGAL,700033
11-Jun-1991 100 SAYANI DASGUPTA OTHER
*Cettified that i have no family as defined in para2 (g) of the Employees' Provident Fund Scheme,1952 and
should I acquire a familly hereafter the above nomination should be deemed as cancelled.
*strike out whichever is not applicable Signature or thumb impression of the Subscriber
* Certified that my father / mother is / are dependent upon me.
PART B (EPS)(Para 18)
I hereby furnish below particulars of the members of my family who would be eligible receive
widow/children pension in the event of my death
Sl.
No
1.
Name and Address of the family member Date Of Birth
4
Relationship with
member
5
Address
3
Name
2
1
I hereby nominate the following person for receving the monthly widow pension (admissible under para 16 2(a)(i)(ii) in the
event of my death wihout leaving any eligible family member for receiving pension
**Certified that I have no family as defined in para 2 (vii)of the Employees' Pension Scheme, 1995 and should I acquire a
family hereafter I shall furnish particulars thereon in above form.
Relationship with the member Date Of Birth Name and Address of Nominee
SAYANI DASGUPTA,14, BISWAS PARA LANE,KOLKATA,KOLKATA,,WEST
BENGAL,700033
11-Jun-1991 OTHER
Name and address of the Factory/
Establishment or rubber stamp thereof
Designation
Signature of the employer or the other
authorized Officers of the establishment
Place :
Date :
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 got confirmed by him/her.
CERTIFICATE BY EMPLOYER
Signature or thumb impression of the Subscriber *strike out whichever is not applicable
Date :
(For Unexempted/ exempted Establishments)
(Paragraph 33 and 61(1) of the Employees ' Provident Fund Scheme, 1952 &
Paragraph 18of the Employees 'Pension Scheme 1995 )
Declaration and Nomination Form under the Employees' Provident Funds & Employess' Pension Scheme
1. Name 2. Father's / Husband Name
3. Date Of Birth 4. Sex
5. Marital Status 6. Account No.
7. E Mail Address 8. Phone No.
9. Address
Permanent
Temporary
I hereby nominate the person(s)/cancel the nomination made by me previously and nominate the person(s) , mention
below receive the amount standing to my credit in the Employee' Provident Fund , in the event of my Death
PART A (EPF)
Name of the
nominee/nominee's
Address Nominee's
relationship with
the member
Date Of
Birth
Total Amount or
Share of
accumulation in
Provident Fund
to be paid to
each nominee
If the nominee is minor
,name & relationship &
address of the guardian
who may receive the
amount during the
NOMINATION AND DECLARATION FORM
C/O DIPANKAR ROUTH,,117, SOUTH STATION ROAD,PO-AGARPARA,KOLKATA,24 PGS NORTH,WEST BENGAL,700109
C/O DIPANKAR ROUTH,,117, SOUTH STATION ROAD,PO-AGARPARA,KOLKATA,24 PGS NORTH,WEST BENGAL,700109
WB/PRB/0053862/000/0000034
FORM2 (Revised)
SUBIR KUMAR BANDYOPADHYAY
07-Aug-1969
MARRIED
PRODOSH KUMAR BANERJEE
MALE
91
,,,,,
C/O DIPANKAR ROUTH,,117,
SOUTH STATION
ROAD,PO-AGARPARA,KOLKA
TA,24 PGS NORTH,WEST
BENGAL,700109
01-Jan-1972 100 SRABONI
BANDYOPADHYAY
WIFE
*Cettified that i have no family as defined in para2 (g) of the Employees' Provident Fund Scheme,1952 and
should I acquire a familly hereafter the above nomination should be deemed as cancelled.
*strike out whichever is not applicable Signature or thumb impression of the Subscriber
* Certified that my father / mother is / are dependent upon me.
PART B (EPS)(Para 18)
I hereby furnish below particulars of the members of my family who would be eligible receive
widow/children pension in the event of my death
Sl.
No
1.
Name and Address of the family member Date Of Birth
4
Relationship with
member
5
Address
3
Name
2
C/O DIPANKAR ROUTH,,KOLKATA,24
PGS NORTH,WEST BENGAL,700109
1 SRABONI BANDYOPADHYAY 01-Jan-1972 WIFE
C/O DIPANKAR ROUTH,,KOLKATA,24
PGS NORTH,,700109
2 SUCHANDRA BANDYOPADHYAY 16-Dec-2004 SON
I hereby nominate the following person for receving the monthly widow pension (admissible under para 16 2(a)(i)(ii) in the
event of my death wihout leaving any eligible family member for receiving pension
**Certified that I have no family as defined in para 2 (vii)of the Employees' Pension Scheme, 1995 and should I acquire a
family hereafter I shall furnish particulars thereon in above form.
Relationship with the member Date Of Birth Name and Address of Nominee
Name and address of the Factory/
Establishment or rubber stamp thereof
Designation
Signature of the employer or the other
authorized Officers of the establishment
Place :
Date :
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 got confirmed by him/her.
CERTIFICATE BY EMPLOYER
Signature or thumb impression of the Subscriber *strike out whichever is not applicable
Date :
(For Unexempted/ exempted Establishments)
(Paragraph 33 and 61(1) of the Employees ' Provident Fund Scheme, 1952 &
Paragraph 18of the Employees 'Pension Scheme 1995 )
Declaration and Nomination Form under the Employees' Provident Funds & Employess' Pension Scheme
1. Name 2. Father's / Husband Name
3. Date Of Birth 4. Sex
5. Marital Status 6. Account No.
7. E Mail Address 8. Phone No.
9. Address
Permanent
Temporary
I hereby nominate the person(s)/cancel the nomination made by me previously and nominate the person(s) , mention
below receive the amount standing to my credit in the Employee' Provident Fund , in the event of my Death
PART A (EPF)
Name of the
nominee/nominee's
Address Nominee's
relationship with
the member
Date Of
Birth
Total Amount or
Share of
accumulation in
Provident Fund
to be paid to
each nominee
If the nominee is minor
,name & relationship &
address of the guardian
who may receive the
amount during the
NOMINATION AND DECLARATION FORM
,,,,,
WB/PRB/0053862/000/0000035
FORM2 (Revised)
SUJIT KUNDU
04-Jan-1971
MARRIED
PAGAL CHANDRA KUNDU
MALE
*Cettified that i have no family as defined in para2 (g) of the Employees' Provident Fund Scheme,1952 and
should I acquire a familly hereafter the above nomination should be deemed as cancelled.
*strike out whichever is not applicable Signature or thumb impression of the Subscriber
* Certified that my father / mother is / are dependent upon me.
PART B (EPS)(Para 18)
I hereby furnish below particulars of the members of my family who would be eligible receive
widow/children pension in the event of my death
Sl.
No
1.
Name and Address of the family member Date Of Birth
4
Relationship with
member
5
Address
3
Name
2
1
I hereby nominate the following person for receving the monthly widow pension (admissible under para 16 2(a)(i)(ii) in the
event of my death wihout leaving any eligible family member for receiving pension
**Certified that I have no family as defined in para 2 (vii)of the Employees' Pension Scheme, 1995 and should I acquire a
family hereafter I shall furnish particulars thereon in above form.
Relationship with the member Date Of Birth Name and Address of Nominee
Name and address of the Factory/
Establishment or rubber stamp thereof
Designation
Signature of the employer or the other
authorized Officers of the establishment
Place :
Date :
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 got confirmed by him/her.
CERTIFICATE BY EMPLOYER
Signature or thumb impression of the Subscriber *strike out whichever is not applicable
Date :
(For Unexempted/ exempted Establishments)
(Paragraph 33 and 61(1) of the Employees ' Provident Fund Scheme, 1952 &
Paragraph 18of the Employees 'Pension Scheme 1995 )
Declaration and Nomination Form under the Employees' Provident Funds & Employess' Pension Scheme
1. Name 2. Father's / Husband Name
3. Date Of Birth 4. Sex
5. Marital Status 6. Account No.
7. E Mail Address 8. Phone No.
9. Address
Permanent
Temporary
I hereby nominate the person(s)/cancel the nomination made by me previously and nominate the person(s) , mention
below receive the amount standing to my credit in the Employee' Provident Fund , in the event of my Death
PART A (EPF)
Name of the
nominee/nominee's
Address Nominee's
relationship with
the member
Date Of
Birth
Total Amount or
Share of
accumulation in
Provident Fund
to be paid to
each nominee
If the nominee is minor
,name & relationship &
address of the guardian
who may receive the
amount during the
NOMINATION AND DECLARATION FORM
MUKUNDAPUR 1134/1 NAYABAD,,KOLKATA,24 PGS SOUTH,WEST BENGAL,700099
MUKUNDAPUR 1134/1 NAYABAD,,KOLKATA,24 PGS SOUTH,WEST BENGAL,700099
WB/PRB/0053862/000/0000036
FORM2 (Revised)
TAPAN LASKAR
29-Jan-1969
MARRIED
LATE AMULYA LASKAR
MALE
9174680930
,,,,,
MUKUNDAPUR 1134/1
NAYABAD,,KOLKATA,24 PGS
SOUTH,WEST
BENGAL,700099
28-Apr-1981 33 REBA LASKAR WIFE
,,,,,
MUKUNDAPUR 1134/1
NAYABAD,,KOLKATA,24 PGS
SOUTH,WEST
BENGAL,700099
21-May-1999 33 RAJ LASKAR SON
,,,,,
MUKUNDAPUR 1134/1
NAYABAD,,KOLKATA,24 PGS
SOUTH,WEST
BENGAL,700099
10-Sep-2009 34 AISHIK LASKAR SON
*Cettified that i have no family as defined in para2 (g) of the Employees' Provident Fund Scheme,1952 and
should I acquire a familly hereafter the above nomination should be deemed as cancelled.
*strike out whichever is not applicable Signature or thumb impression of the Subscriber
* Certified that my father / mother is / are dependent upon me.
PART B (EPS)(Para 18)
I hereby furnish below particulars of the members of my family who would be eligible receive
widow/children pension in the event of my death
Sl.
No
1.
Name and Address of the family member Date Of Birth
4
Relationship with
member
5
Address
3
Name
2
MUKUNDAPUR 1134/1
NAYABAD,KOLKATA,24 PGS
1 REBA LASKAR 28-Apr-1981 WIFE
MUKUNDAPUR 1134/1
NAYABAD,KOLKATA,24 PGS
2 RAJ LASKAR 21-May-1999 SON
MUKUNDAPUR 1134/1
NAYABAD,KOLKATA,24 PGS
3 AISHIK LASKAR 10-Sep-2009 SON
I hereby nominate the following person for receving the monthly widow pension (admissible under para 16 2(a)(i)(ii) in the
event of my death wihout leaving any eligible family member for receiving pension
**Certified that I have no family as defined in para 2 (vii)of the Employees' Pension Scheme, 1995 and should I acquire a
family hereafter I shall furnish particulars thereon in above form.
Relationship with the member Date Of Birth Name and Address of Nominee
Name and address of the Factory/
Establishment or rubber stamp thereof
Designation
Signature of the employer or the other
authorized Officers of the establishment
Place :
Date :
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 got confirmed by him/her.
CERTIFICATE BY EMPLOYER
Signature or thumb impression of the Subscriber *strike out whichever is not applicable
Date :
(For Unexempted/ exempted Establishments)
(Paragraph 33 and 61(1) of the Employees ' Provident Fund Scheme, 1952 &
Paragraph 18of the Employees 'Pension Scheme 1995 )
Declaration and Nomination Form under the Employees' Provident Funds & Employess' Pension Scheme
1. Name 2. Father's / Husband Name
3. Date Of Birth 4. Sex
5. Marital Status 6. Account No.
7. E Mail Address 8. Phone No.
9. Address
Permanent
Temporary
I hereby nominate the person(s)/cancel the nomination made by me previously and nominate the person(s) , mention
below receive the amount standing to my credit in the Employee' Provident Fund , in the event of my Death
PART A (EPF)
Name of the
nominee/nominee's
Address Nominee's
relationship with
the member
Date Of
Birth
Total Amount or
Share of
accumulation in
Provident Fund
to be paid to
each nominee
If the nominee is minor
,name & relationship &
address of the guardian
who may receive the
amount during the
NOMINATION AND DECLARATION FORM
54, SURYA SEN NAGAR,PO-MOTIJHEEL, PS-DUMDUM,KOLKATA,24 PGS NORTH,WEST BENGAL,700074
54, SURYA SEN NAGAR,PO-MOTIJHEEL, PS-DUMDUM,KOLKATA,24 PGS NORTH,WEST BENGAL,700074
WB/PRB/0053862/000/0000037
FORM2 (Revised)
TARUN KUMAR DEY
27-Apr-1976
MARRIED
LATE HARIPADA DEY
MALE
9148325227
,,,,,
54, SURYA SEN
NAGAR,PO-MOTIJHEEL,
PS-DUMDUM,KOLKATA,24
PGS NORTH,WEST
BENGAL,700074
22-Jul-1981 100 SUPARNA DEY WIFE
*Cettified that i have no family as defined in para2 (g) of the Employees' Provident Fund Scheme,1952 and
should I acquire a familly hereafter the above nomination should be deemed as cancelled.
*strike out whichever is not applicable Signature or thumb impression of the Subscriber
* Certified that my father / mother is / are dependent upon me.
PART B (EPS)(Para 18)
I hereby furnish below particulars of the members of my family who would be eligible receive
widow/children pension in the event of my death
Sl.
No
1.
Name and Address of the family member Date Of Birth
4
Relationship with
member
5
Address
3
Name
2
54, SURYA SEN NAGAR,KOLKATA,24
PGS NORTH,,700074
1 SUPARNA DEY 22-Jul-1981 WIFE
I hereby nominate the following person for receving the monthly widow pension (admissible under para 16 2(a)(i)(ii) in the
event of my death wihout leaving any eligible family member for receiving pension
**Certified that I have no family as defined in para 2 (vii)of the Employees' Pension Scheme, 1995 and should I acquire a
family hereafter I shall furnish particulars thereon in above form.
Relationship with the member Date Of Birth Name and Address of Nominee
Name and address of the Factory/
Establishment or rubber stamp thereof
Designation
Signature of the employer or the other
authorized Officers of the establishment
Place :
Date :
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 got confirmed by him/her.
CERTIFICATE BY EMPLOYER
Signature or thumb impression of the Subscriber *strike out whichever is not applicable
Date :
(For Unexempted/ exempted Establishments)
(Paragraph 33 and 61(1) of the Employees ' Provident Fund Scheme, 1952 &
Paragraph 18of the Employees 'Pension Scheme 1995 )
Declaration and Nomination Form under the Employees' Provident Funds & Employess' Pension Scheme
1. Name 2. Father's / Husband Name
3. Date Of Birth 4. Sex
5. Marital Status 6. Account No.
7. E Mail Address 8. Phone No.
9. Address
Permanent
Temporary
I hereby nominate the person(s)/cancel the nomination made by me previously and nominate the person(s) , mention
below receive the amount standing to my credit in the Employee' Provident Fund , in the event of my Death
PART A (EPF)
Name of the
nominee/nominee's
Address Nominee's
relationship with
the member
Date Of
Birth
Total Amount or
Share of
accumulation in
Provident Fund
to be paid to
each nominee
If the nominee is minor
,name & relationship &
address of the guardian
who may receive the
amount during the
NOMINATION AND DECLARATION FORM
,,,,,
WB/PRB/0053862/000/0000038
FORM2 (Revised)
UTPALADITYA BANERJEE
24-Jul-1958
MARRIED
RANJIT BANERJEE
MALE
*Cettified that i have no family as defined in para2 (g) of the Employees' Provident Fund Scheme,1952 and
should I acquire a familly hereafter the above nomination should be deemed as cancelled.
*strike out whichever is not applicable Signature or thumb impression of the Subscriber
* Certified that my father / mother is / are dependent upon me.
PART B (EPS)(Para 18)
I hereby furnish below particulars of the members of my family who would be eligible receive
widow/children pension in the event of my death
Sl.
No
1.
Name and Address of the family member Date Of Birth
4
Relationship with
member
5
Address
3
Name
2
1
I hereby nominate the following person for receving the monthly widow pension (admissible under para 16 2(a)(i)(ii) in the
event of my death wihout leaving any eligible family member for receiving pension
**Certified that I have no family as defined in para 2 (vii)of the Employees' Pension Scheme, 1995 and should I acquire a
family hereafter I shall furnish particulars thereon in above form.
Relationship with the member Date Of Birth Name and Address of Nominee
Name and address of the Factory/
Establishment or rubber stamp thereof
Designation
Signature of the employer or the other
authorized Officers of the establishment
Place :
Date :
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 got confirmed by him/her.
CERTIFICATE BY EMPLOYER
Signature or thumb impression of the Subscriber *strike out whichever is not applicable
Date :
(For Unexempted/ exempted Establishments)
(Paragraph 33 and 61(1) of the Employees ' Provident Fund Scheme, 1952 &
Paragraph 18of the Employees 'Pension Scheme 1995 )
Declaration and Nomination Form under the Employees' Provident Funds & Employess' Pension Scheme
1. Name 2. Father's / Husband Name
3. Date Of Birth 4. Sex
5. Marital Status 6. Account No.
7. E Mail Address 8. Phone No.
9. Address
Permanent
Temporary
I hereby nominate the person(s)/cancel the nomination made by me previously and nominate the person(s) , mention
below receive the amount standing to my credit in the Employee' Provident Fund , in the event of my Death
PART A (EPF)
Name of the
nominee/nominee's
Address Nominee's
relationship with
the member
Date Of
Birth
Total Amount or
Share of
accumulation in
Provident Fund
to be paid to
each nominee
If the nominee is minor
,name & relationship &
address of the guardian
who may receive the
amount during the
NOMINATION AND DECLARATION FORM
PATIPUKUR,1 NO PALLI SREE COLONY,EP-72, KOLKATA,24 PGS NORTH,WEST BENGAL,700048
PATIPUKUR,1 NO PALLI SREE COLONY,EP-72, KOLKATA,24 PGS NORTH,WEST BENGAL,700048
WB/PRB/0053862/000/0000039
FORM2 (Revised)
JAYANTA NAG
01-Jan-1971
MARRIED
LATE SURJYA KANTA NAG
MALE
9130914067 nag_jayanta@yahoo.com
,,,,,
PATIPUKUR,1 NO PALLI SREE
COLONY,EP-72, KOLKATA,24
PGS NORTH,WEST
BENGAL,700048
01-Jan-1984 50 CHITRA NAG WIFE
,,,,,
PATIPUKUR,1 NO PALLI SREE
COLONY,EP-72, KOLKATA,24
PGS NORTH,WEST
BENGAL,700048
03-Dec-2007 50 SUN NAG SON
*Cettified that i have no family as defined in para2 (g) of the Employees' Provident Fund Scheme,1952 and
should I acquire a familly hereafter the above nomination should be deemed as cancelled.
*strike out whichever is not applicable Signature or thumb impression of the Subscriber
* Certified that my father / mother is / are dependent upon me.
PART B (EPS)(Para 18)
I hereby furnish below particulars of the members of my family who would be eligible receive
widow/children pension in the event of my death
Sl.
No
1.
Name and Address of the family member Date Of Birth
4
Relationship with
member
5
Address
3
Name
2
PATIPUKUR,EP-72, KOLKATA,24 PGS
NORTH,,700048
1 CHITRA NAG 01-Jan-1984 WIFE
PATIPUKUR,EP-72, KOLKATA,24 PGS
NORTH,WEST BENGAL,700048
2 SUN NAG 03-Dec-2007 SON
I hereby nominate the following person for receving the monthly widow pension (admissible under para 16 2(a)(i)(ii) in the
event of my death wihout leaving any eligible family member for receiving pension
**Certified that I have no family as defined in para 2 (vii)of the Employees' Pension Scheme, 1995 and should I acquire a
family hereafter I shall furnish particulars thereon in above form.
Relationship with the member Date Of Birth Name and Address of Nominee
Name and address of the Factory/
Establishment or rubber stamp thereof
Designation
Signature of the employer or the other
authorized Officers of the establishment
Place :
Date :
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 got confirmed by him/her.
CERTIFICATE BY EMPLOYER
Signature or thumb impression of the Subscriber *strike out whichever is not applicable
Date :
(For Unexempted/ exempted Establishments)
(Paragraph 33 and 61(1) of the Employees ' Provident Fund Scheme, 1952 &
Paragraph 18of the Employees 'Pension Scheme 1995 )
Declaration and Nomination Form under the Employees' Provident Funds & Employess' Pension Scheme
1. Name 2. Father's / Husband Name
3. Date Of Birth 4. Sex
5. Marital Status 6. Account No.
7. E Mail Address 8. Phone No.
9. Address
Permanent
Temporary
I hereby nominate the person(s)/cancel the nomination made by me previously and nominate the person(s) , mention
below receive the amount standing to my credit in the Employee' Provident Fund , in the event of my Death
PART A (EPF)
Name of the
nominee/nominee's
Address Nominee's
relationship with
the member
Date Of
Birth
Total Amount or
Share of
accumulation in
Provident Fund
to be paid to
each nominee
If the nominee is minor
,name & relationship &
address of the guardian
who may receive the
amount during the
NOMINATION AND DECLARATION FORM
81, NILGANJ ROAD, PANJA VILLA,AGARPARA,KOLKATA,24 PGS NORTH,WEST BENGAL,700109
81, NILGANJ ROAD, PANJA VILLA,AGARPARA,KOLKATA,24 PGS NORTH,WEST BENGAL,700109
WB/PRB/0053862/000/0000004
FORM2 (Revised)
ABDUL MAZEED
03-Jun-1968
MARRIED
NOOR MOHAMMED
MALE
9130248811
,,,,,
81, NILGANJ ROAD, PANJA
VILLA,AGARPARA,KOLKATA,2
4 PGS NORTH,WEST
BENGAL,700109
01-Aug-1974 25 HASINA BANU WIFE
,,,,,
81, NILGANJ ROAD, PANJA
VILLA,AGARPARA,KOLKATA,2
4 PGS NORTH,WEST
BENGAL,700109
23-Jan-1994 25 LADLY BANO DAUGHTER
,,,,,
81, NILGANJ ROAD, PANJA
VILLA,AGARPARA,KOLKATA,2
4 PGS NORTH,WEST
BENGAL,700109
17-Mar-1996 25 TWINKLE BANO DAUGHTER
,,,,,
81, NILGANJ ROAD, PANJA
VILLA,AGARPARA,KOLKATA,2
4 PGS NORTH,WEST
BENGAL,700109
12-Jun-2004 25 ADIL KHAN SON
*Cettified that i have no family as defined in para2 (g) of the Employees' Provident Fund Scheme,1952 and
should I acquire a familly hereafter the above nomination should be deemed as cancelled.
*strike out whichever is not applicable Signature or thumb impression of the Subscriber
* Certified that my father / mother is / are dependent upon me.
PART B (EPS)(Para 18)
I hereby furnish below particulars of the members of my family who would be eligible receive
widow/children pension in the event of my death
Sl.
No
1.
Name and Address of the family member Date Of Birth
4
Relationship with
member
5
Address
3
Name
2
81, NILGANJ ROAD, PANJA
VILLA,KOLKATA,24 PGS
1 HASINA BANU 01-Aug-1974 WIFE
81, NILGANJ ROAD, PANJA
VILLA,KOLKATA,24 PGS NORTH,WEST
2 LADLY BANO 23-Jan-1994 DAUGHTER
81, NILGANJ ROAD, PANJA
VILLA,KOLKATA,24 PGS NORTH,WEST
3 TWINKLE BANO 17-Mar-1996 DAUGHTER
81, NILGANJ ROAD, PANJA
VILLA,KOLKATA,24 PGS NORTH,WEST
4 ADIL KHAN 12-Jun-2004 SON
I hereby nominate the following person for receving the monthly widow pension (admissible under para 16 2(a)(i)(ii) in the
event of my death wihout leaving any eligible family member for receiving pension
**Certified that I have no family as defined in para 2 (vii)of the Employees' Pension Scheme, 1995 and should I acquire a
family hereafter I shall furnish particulars thereon in above form.
Relationship with the member Date Of Birth Name and Address of Nominee
Name and address of the Factory/
Establishment or rubber stamp thereof
Designation
Signature of the employer or the other
authorized Officers of the establishment
Place :
Date :
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 got confirmed by him/her.
CERTIFICATE BY EMPLOYER
Signature or thumb impression of the Subscriber *strike out whichever is not applicable
Date :
(For Unexempted/ exempted Establishments)
(Paragraph 33 and 61(1) of the Employees ' Provident Fund Scheme, 1952 &
Paragraph 18of the Employees 'Pension Scheme 1995 )
Declaration and Nomination Form under the Employees' Provident Funds & Employess' Pension Scheme
1. Name 2. Father's / Husband Name
3. Date Of Birth 4. Sex
5. Marital Status 6. Account No.
7. E Mail Address 8. Phone No.
9. Address
Permanent
Temporary
I hereby nominate the person(s)/cancel the nomination made by me previously and nominate the person(s) , mention
below receive the amount standing to my credit in the Employee' Provident Fund , in the event of my Death
PART A (EPF)
Name of the
nominee/nominee's
Address Nominee's
relationship with
the member
Date Of
Birth
Total Amount or
Share of
accumulation in
Provident Fund
to be paid to
each nominee
If the nominee is minor
,name & relationship &
address of the guardian
who may receive the
amount during the
NOMINATION AND DECLARATION FORM
5/24, RAJENDRA PRASAD COLONY,PO-TOLLYGUNGE, PS-JADAVPUR,KOLKATA,,WEST BENGAL,700033
5/24, RAJENDRA PRASAD COLONY,PO-TOLLYGUNGE, PS-JADAVPUR,KOLKATA,,WEST BENGAL,700033
WB/PRB/0053862/000/0000040
FORM2 (Revised)
DIPANKAR DAS
20-Nov-1993
UNMARRIED
DIPU DAS
MALE
7278387953 dipankar.das211@gmail.com
,,,,,
5/24, RAJENDRA PRASAD
COLONY,PO-TOLLYGUNGE,
PS-JADAVPUR,KOLKATA,,WE
ST BENGAL,700033
01-Jan-1962 40 DIPU DAS DEPENDENT FATHER
,,,,,
5/24, RAJENDRA PRASAD
COLONY,PO-TOLLYGUNGE,
PS-JADAVPUR,KOLKATA,,WE
ST BENGAL,700033
10-May-1967 60 MITHU DAS DEPENDENT MOTHER
*Cettified that i have no family as defined in para2 (g) of the Employees' Provident Fund Scheme,1952 and
should I acquire a familly hereafter the above nomination should be deemed as cancelled.
*strike out whichever is not applicable Signature or thumb impression of the Subscriber
* Certified that my father / mother is / are dependent upon me.
PART B (EPS)(Para 18)
I hereby furnish below particulars of the members of my family who would be eligible receive
widow/children pension in the event of my death
Sl.
No
1.
Name and Address of the family member Date Of Birth
4
Relationship with
member
5
Address
3
Name
2
1
I hereby nominate the following person for receving the monthly widow pension (admissible under para 16 2(a)(i)(ii) in the
event of my death wihout leaving any eligible family member for receiving pension
**Certified that I have no family as defined in para 2 (vii)of the Employees' Pension Scheme, 1995 and should I acquire a
family hereafter I shall furnish particulars thereon in above form.
Relationship with the member Date Of Birth Name and Address of Nominee
MITHU DAS,5/24, RAJENDRA PRASAD COLONY,PO-TOLLYGUNGE,
PS-JADAVPUR,KOLKATA,,WEST BENGAL,700033
10-May-1967 DEPENDENT MOTHER
Name and address of the Factory/
Establishment or rubber stamp thereof
Designation
Signature of the employer or the other
authorized Officers of the establishment
Place :
Date :
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 got confirmed by him/her.
CERTIFICATE BY EMPLOYER
Signature or thumb impression of the Subscriber *strike out whichever is not applicable
Date :
(For Unexempted/ exempted Establishments)
(Paragraph 33 and 61(1) of the Employees ' Provident Fund Scheme, 1952 &
Paragraph 18of the Employees 'Pension Scheme 1995 )
Declaration and Nomination Form under the Employees' Provident Funds & Employess' Pension Scheme
1. Name 2. Father's / Husband Name
3. Date Of Birth 4. Sex
5. Marital Status 6. Account No.
7. E Mail Address 8. Phone No.
9. Address
Permanent
Temporary
I hereby nominate the person(s)/cancel the nomination made by me previously and nominate the person(s) , mention
below receive the amount standing to my credit in the Employee' Provident Fund , in the event of my Death
PART A (EPF)
Name of the
nominee/nominee's
Address Nominee's
relationship with
the member
Date Of
Birth
Total Amount or
Share of
accumulation in
Provident Fund
to be paid to
each nominee
If the nominee is minor
,name & relationship &
address of the guardian
who may receive the
amount during the
NOMINATION AND DECLARATION FORM
VILL-BARISHAL COLONY,PO PS- CHAKDAHA,,NADIA,WEST BENGAL,741222
VILL-BARISHAL COLONY,PO PS- CHAKDAHA,,NADIA,WEST BENGAL,741222
WB/PRB/0053862/000/0000041
FORM2 (Revised)
SANJOY KUMAR BISWAS
10-Jan-1979
MARRIED
DHRUBA BISWAS
MALE
8420005833
,,,,,
VILL-BARISHAL COLONY,PO
PS-
CHAKDAHA,,NADIA,WEST
BENGAL,741222
23-Aug-1981 50 RUMA DAS BISWAS WIFE
,,,,,
VILL-BARISHAL COLONY,PO
PS-
CHAKDAHA,,NADIA,WEST
BENGAL,741222
26-Feb-2001 50 RITURAJ BISWAS SON
*Cettified that i have no family as defined in para2 (g) of the Employees' Provident Fund Scheme,1952 and
should I acquire a familly hereafter the above nomination should be deemed as cancelled.
*strike out whichever is not applicable Signature or thumb impression of the Subscriber
* Certified that my father / mother is / are dependent upon me.
PART B (EPS)(Para 18)
I hereby furnish below particulars of the members of my family who would be eligible receive
widow/children pension in the event of my death
Sl.
No
1.
Name and Address of the family member Date Of Birth
4
Relationship with
member
5
Address
3
Name
2
VILL-BARISHAL COLONY,,NADIA,WEST
BENGAL,741222
1 RUMA DAS BISWAS 23-Aug-1981 WIFE
VILL-BARISHAL
COLONY,,NADIA,,741222
2 RITURAJ BISWAS 26-Feb-2001 SON
I hereby nominate the following person for receving the monthly widow pension (admissible under para 16 2(a)(i)(ii) in the
event of my death wihout leaving any eligible family member for receiving pension
**Certified that I have no family as defined in para 2 (vii)of the Employees' Pension Scheme, 1995 and should I acquire a
family hereafter I shall furnish particulars thereon in above form.
Relationship with the member Date Of Birth Name and Address of Nominee
Name and address of the Factory/
Establishment or rubber stamp thereof
Designation
Signature of the employer or the other
authorized Officers of the establishment
Place :
Date :
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 got confirmed by him/her.
CERTIFICATE BY EMPLOYER
Signature or thumb impression of the Subscriber *strike out whichever is not applicable
Date :
(For Unexempted/ exempted Establishments)
(Paragraph 33 and 61(1) of the Employees ' Provident Fund Scheme, 1952 &
Paragraph 18of the Employees 'Pension Scheme 1995 )
Declaration and Nomination Form under the Employees' Provident Funds & Employess' Pension Scheme
1. Name 2. Father's / Husband Name
3. Date Of Birth 4. Sex
5. Marital Status 6. Account No.
7. E Mail Address 8. Phone No.
9. Address
Permanent
Temporary
I hereby nominate the person(s)/cancel the nomination made by me previously and nominate the person(s) , mention
below receive the amount standing to my credit in the Employee' Provident Fund , in the event of my Death
PART A (EPF)
Name of the
nominee/nominee's
Address Nominee's
relationship with
the member
Date Of
Birth
Total Amount or
Share of
accumulation in
Provident Fund
to be paid to
each nominee
If the nominee is minor
,name & relationship &
address of the guardian
who may receive the
amount during the
NOMINATION AND DECLARATION FORM
18/1, KALIKAPUR ROAD,KMC PREMISES NO900A/1,PO-MUKUNDAPUR, KOLKATA,SOUTH 24 PGS,WEST BENGAL,700099
18/1, KALIKAPUR ROAD,KMC PREMISES NO900A/1,PO-MUKUNDAPUR, KOLKATA,SOUTH 24 PGS,WEST BENGAL,700099
WB/PRB/0053862/000/0000042
FORM2 (Revised)
SHAIBAL BHATTACHARJEE
01-Jan-1987
UNMARRIED
SWAPAN KUMAR BHATTACHARJEE
MALE
9432834847 shaibal.bhattacharjee87@gmail.com
,,,,,
18/1, KALIKAPUR ROAD,KMC
PREMISES
NO900A/1,PO-MUKUNDAPUR,
KOLKATA,SOUTH24
PGS,WEST BENGAL,700099
13-Apr-1952 50 SWAPAN KR
BHATTACHARJEE
DEPENDENT FATHER
,,,,,
18/1, KALIKAPUR ROAD,KMC
PREMISES
NO900A/1,PO-MUKUNDAPUR,
KOLKATA,SOUTH24
PGS,WEST BENGAL,700099
26-Jul-1963 50 TAPOSI
BHATTACHARJEE
DEPENDENT MOTHER
*Cettified that i have no family as defined in para2 (g) of the Employees' Provident Fund Scheme,1952 and
should I acquire a familly hereafter the above nomination should be deemed as cancelled.
*strike out whichever is not applicable Signature or thumb impression of the Subscriber
* Certified that my father / mother is / are dependent upon me.
PART B (EPS)(Para 18)
I hereby furnish below particulars of the members of my family who would be eligible receive
widow/children pension in the event of my death
Sl.
No
1.
Name and Address of the family member Date Of Birth
4
Relationship with
member
5
Address
3
Name
2
1
I hereby nominate the following person for receving the monthly widow pension (admissible under para 16 2(a)(i)(ii) in the
event of my death wihout leaving any eligible family member for receiving pension
**Certified that I have no family as defined in para 2 (vii)of the Employees' Pension Scheme, 1995 and should I acquire a
family hereafter I shall furnish particulars thereon in above form.
Relationship with the member Date Of Birth Name and Address of Nominee
TAPOSI BHATTACHARJEE,18/1, KALIKAPUR ROAD,KMC PREMISES
NO900A/1,PO-MUKUNDAPUR, KOLKATA,SOUTH24 PGS,WEST
26-Jul-1963 DEPENDENT MOTHER
Name and address of the Factory/
Establishment or rubber stamp thereof
Designation
Signature of the employer or the other
authorized Officers of the establishment
Place :
Date :
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 got confirmed by him/her.
CERTIFICATE BY EMPLOYER
Signature or thumb impression of the Subscriber *strike out whichever is not applicable
Date :
(For Unexempted/ exempted Establishments)
(Paragraph 33 and 61(1) of the Employees ' Provident Fund Scheme, 1952 &
Paragraph 18of the Employees 'Pension Scheme 1995 )
Declaration and Nomination Form under the Employees' Provident Funds & Employess' Pension Scheme
1. Name 2. Father's / Husband Name
3. Date Of Birth 4. Sex
5. Marital Status 6. Account No.
7. E Mail Address 8. Phone No.
9. Address
Permanent
Temporary
I hereby nominate the person(s)/cancel the nomination made by me previously and nominate the person(s) , mention
below receive the amount standing to my credit in the Employee' Provident Fund , in the event of my Death
PART A (EPF)
Name of the
nominee/nominee's
Address Nominee's
relationship with
the member
Date Of
Birth
Total Amount or
Share of
accumulation in
Provident Fund
to be paid to
each nominee
If the nominee is minor
,name & relationship &
address of the guardian
who may receive the
amount during the
NOMINATION AND DECLARATION FORM
J.C.BOSE ROAD BYLANE, KHELA GHAR,MORE, HAKIMPARA,SILIGURI,DARJEELING,WEST BENGAL,734001
J.C.BOSE ROAD BYLANE, KHELA GHAR,MORE, HAKIMPARA,SILIGURI,DARJEELING,WEST BENGAL,734001
WB/PRB/0053862/000/0000043
FORM2 (Revised)
DIPAK MOHANTA
05-Jul-1976
MARRIED
DINABANDHU MOHANTA
MALE
8420005851 dipakslg1979@rediff.co.in
,,,,,
J.C.BOSE ROAD BYLANE,
KHELA GHAR,MORE,
HAKIMPARA,SILIGURI,DARJE
ELING,WEST BENGAL,734001
14-Dec-1978 50 MAHUA MOHANTA WIFE
,,,,,
J.C.BOSE ROAD BYLANE,
KHELA GHAR,MORE,
HAKIMPARA,SILIGURI,DARJE
ELING,WEST BENGAL,734001
27-Aug-2006 50 RITISHA MOHANTA DAUGHTER
*Cettified that i have no family as defined in para2 (g) of the Employees' Provident Fund Scheme,1952 and
should I acquire a familly hereafter the above nomination should be deemed as cancelled.
*strike out whichever is not applicable Signature or thumb impression of the Subscriber
* Certified that my father / mother is / are dependent upon me.
PART B (EPS)(Para 18)
I hereby furnish below particulars of the members of my family who would be eligible receive
widow/children pension in the event of my death
Sl.
No
1.
Name and Address of the family member Date Of Birth
4
Relationship with
member
5
Address
3
Name
2
J.C.BOSE ROAD BYLANE, KHELA
GHAR,SILIGURI,DARJEELING,,734001
1 MAHUA MOHANTA 14-Dec-1978 WIFE
J.C.BOSE ROAD BYLANE, KHELA
GHAR,SILIGURI,DARJEELING,WEST
2 RITISHA MOHANTA 27-Aug-2006 DAUGHTER
I hereby nominate the following person for receving the monthly widow pension (admissible under para 16 2(a)(i)(ii) in the
event of my death wihout leaving any eligible family member for receiving pension
**Certified that I have no family as defined in para 2 (vii)of the Employees' Pension Scheme, 1995 and should I acquire a
family hereafter I shall furnish particulars thereon in above form.
Relationship with the member Date Of Birth Name and Address of Nominee
Name and address of the Factory/
Establishment or rubber stamp thereof
Designation
Signature of the employer or the other
authorized Officers of the establishment
Place :
Date :
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 got confirmed by him/her.
CERTIFICATE BY EMPLOYER
Signature or thumb impression of the Subscriber *strike out whichever is not applicable
Date :
(For Unexempted/ exempted Establishments)
(Paragraph 33 and 61(1) of the Employees ' Provident Fund Scheme, 1952 &
Paragraph 18of the Employees 'Pension Scheme 1995 )
Declaration and Nomination Form under the Employees' Provident Funds & Employess' Pension Scheme
1. Name 2. Father's / Husband Name
3. Date Of Birth 4. Sex
5. Marital Status 6. Account No.
7. E Mail Address 8. Phone No.
9. Address
Permanent
Temporary
I hereby nominate the person(s)/cancel the nomination made by me previously and nominate the person(s) , mention
below receive the amount standing to my credit in the Employee' Provident Fund , in the event of my Death
PART A (EPF)
Name of the
nominee/nominee's
Address Nominee's
relationship with
the member
Date Of
Birth
Total Amount or
Share of
accumulation in
Provident Fund
to be paid to
each nominee
If the nominee is minor
,name & relationship &
address of the guardian
who may receive the
amount during the
NOMINATION AND DECLARATION FORM
82/4B,BIDHAN SARANI,KOLKATA,KOLKATA,WEST BENGAL,700004
82/4B,BIDHAN SARANI,KOLKATA,KOLKATA,WEST BENGAL,700004
WB/PRB/0053862/000/0000044
FORM2 (Revised)
SANJAY KUMAR SHAW
11-May-1990
UNMARRIED
SUBHASH PRASAD SHAW
MALE
9883411753 sanjayshaw20088@gmail.com
,,,,,
82/4B,BIDHAN
SARANI,KOLKATA,KOLKATA,
WEST BENGAL,700004
01-Jan-1962 100 SUBHASH PRASAD
SHAW
DEPENDENT FATHER
*Cettified that i have no family as defined in para2 (g) of the Employees' Provident Fund Scheme,1952 and
should I acquire a familly hereafter the above nomination should be deemed as cancelled.
*strike out whichever is not applicable Signature or thumb impression of the Subscriber
* Certified that my father / mother is / are dependent upon me.
PART B (EPS)(Para 18)
I hereby furnish below particulars of the members of my family who would be eligible receive
widow/children pension in the event of my death
Sl.
No
1.
Name and Address of the family member Date Of Birth
4
Relationship with
member
5
Address
3
Name
2
1
I hereby nominate the following person for receving the monthly widow pension (admissible under para 16 2(a)(i)(ii) in the
event of my death wihout leaving any eligible family member for receiving pension
**Certified that I have no family as defined in para 2 (vii)of the Employees' Pension Scheme, 1995 and should I acquire a
family hereafter I shall furnish particulars thereon in above form.
Relationship with the member Date Of Birth Name and Address of Nominee
SUBHASH PRASAD SHAW,82/4B,BIDHAN
SARANI,KOLKATA,KOLKATA,WEST BENGAL,700004
01-Jan-1962 DEPENDENT FATHER
Name and address of the Factory/
Establishment or rubber stamp thereof
Designation
Signature of the employer or the other
authorized Officers of the establishment
Place :
Date :
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 got confirmed by him/her.
CERTIFICATE BY EMPLOYER
Signature or thumb impression of the Subscriber *strike out whichever is not applicable
Date :
(For Unexempted/ exempted Establishments)
(Paragraph 33 and 61(1) of the Employees ' Provident Fund Scheme, 1952 &
Paragraph 18of the Employees 'Pension Scheme 1995 )
Declaration and Nomination Form under the Employees' Provident Funds & Employess' Pension Scheme
1. Name 2. Father's / Husband Name
3. Date Of Birth 4. Sex
5. Marital Status 6. Account No.
7. E Mail Address 8. Phone No.
9. Address
Permanent
Temporary
I hereby nominate the person(s)/cancel the nomination made by me previously and nominate the person(s) , mention
below receive the amount standing to my credit in the Employee' Provident Fund , in the event of my Death
PART A (EPF)
Name of the
nominee/nominee's
Address Nominee's
relationship with
the member
Date Of
Birth
Total Amount or
Share of
accumulation in
Provident Fund
to be paid to
each nominee
If the nominee is minor
,name & relationship &
address of the guardian
who may receive the
amount during the
NOMINATION AND DECLARATION FORM
TENTULTALA, PURBACHAL,LANE NO 10, PO-RAJARHAT GOPALPUR,KOLKATA,NORTH 24 PGS,WEST BENGAL,700136
TENTULTALA, PURBACHAL,LANE NO 10, PO-RAJARHAT GOPALPUR,KOLKATA,NORTH 24 PGS,WEST BENGAL,700136
WB/PRB/0053862/000/0000045
FORM2 (Revised)
PRASANTA HAZRA
20-Jan-1982
MARRIED
SRIKANTA HAZRA
MALE
9831461660 prasanta.hazra39@gmail.com
,,,,,
TENTULTALA,
PURBACHAL,LANE NO 10,
PO-RAJARHAT
GOPALPUR,KOLKATA,NORTH
24 PGS,WEST
BENGAL,700136
20-Mar-1989 50 SOUMI HAZRA WIFE
,,,,,
TENTULTALA,
PURBACHAL,LANE NO 10,
PO-RAJARHAT
GOPALPUR,KOLKATA,NORTH
24 PGS,WEST
BENGAL,700136
28-Aug-2011 50 POULOMI HAZRA DAUGHTER
*Cettified that i have no family as defined in para2 (g) of the Employees' Provident Fund Scheme,1952 and
should I acquire a familly hereafter the above nomination should be deemed as cancelled.
*strike out whichever is not applicable Signature or thumb impression of the Subscriber
* Certified that my father / mother is / are dependent upon me.
PART B (EPS)(Para 18)
I hereby furnish below particulars of the members of my family who would be eligible receive
widow/children pension in the event of my death
Sl.
No
1.
Name and Address of the family member Date Of Birth
4
Relationship with
member
5
Address
3
Name
2
TENTULTALA,
PURBACHAL,KOLKATA,NORTH24
1 SOUMI HAZRA 20-Mar-1989 WIFE
TENTULTALA,
PURBACHAL,KOLKATA,NORTH24
2 POULOMI HAZRA 28-Aug-2011 DAUGHTER
I hereby nominate the following person for receving the monthly widow pension (admissible under para 16 2(a)(i)(ii) in the
event of my death wihout leaving any eligible family member for receiving pension
**Certified that I have no family as defined in para 2 (vii)of the Employees' Pension Scheme, 1995 and should I acquire a
family hereafter I shall furnish particulars thereon in above form.
Relationship with the member Date Of Birth Name and Address of Nominee
Name and address of the Factory/
Establishment or rubber stamp thereof
Designation
Signature of the employer or the other
authorized Officers of the establishment
Place :
Date :
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 got confirmed by him/her.
CERTIFICATE BY EMPLOYER
Signature or thumb impression of the Subscriber *strike out whichever is not applicable
Date :
(For Unexempted/ exempted Establishments)
(Paragraph 33 and 61(1) of the Employees ' Provident Fund Scheme, 1952 &
Paragraph 18of the Employees 'Pension Scheme 1995 )
Declaration and Nomination Form under the Employees' Provident Funds & Employess' Pension Scheme
1. Name 2. Father's / Husband Name
3. Date Of Birth 4. Sex
5. Marital Status 6. Account No.
7. E Mail Address 8. Phone No.
9. Address
Permanent
Temporary
I hereby nominate the person(s)/cancel the nomination made by me previously and nominate the person(s) , mention
below receive the amount standing to my credit in the Employee' Provident Fund , in the event of my Death
PART A (EPF)
Name of the
nominee/nominee's
Address Nominee's
relationship with
the member
Date Of
Birth
Total Amount or
Share of
accumulation in
Provident Fund
to be paid to
each nominee
If the nominee is minor
,name & relationship &
address of the guardian
who may receive the
amount during the
NOMINATION AND DECLARATION FORM
DONBOSCO PARA, MISSION GATE,,PO-DAYABARI,RANAGHAT,NADIA,WEST BENGAL,741256
DONBOSCO PARA, MISSION GATE,,PO-DAYABARI,RANAGHAT,NADIA,WEST BENGAL,741256
WB/PRB/0053862/000/0000046
FORM2 (Revised)
SANJAY GOMES
03-Apr-1977
MARRIED
LATE BERNARD GOMES
MALE
9163958463 sanjaygomes23@gmail.com
,,,,,
DONBOSCO PARA, MISSION
GATE,,PO-DAYABARI,RANAG
HAT,NADIA,WEST
BENGAL,741256
26-May-1980 100 LILY GOMES WIFE
*Cettified that i have no family as defined in para2 (g) of the Employees' Provident Fund Scheme,1952 and
should I acquire a familly hereafter the above nomination should be deemed as cancelled.
*strike out whichever is not applicable Signature or thumb impression of the Subscriber
* Certified that my father / mother is / are dependent upon me.
PART B (EPS)(Para 18)
I hereby furnish below particulars of the members of my family who would be eligible receive
widow/children pension in the event of my death
Sl.
No
1.
Name and Address of the family member Date Of Birth
4
Relationship with
member
5
Address
3
Name
2
DONBOSCO PARA, MISSION
GATE,,RANAGHAT,NADIA,,741256
1 LILY GOMES 26-May-1980 WIFE
I hereby nominate the following person for receving the monthly widow pension (admissible under para 16 2(a)(i)(ii) in the
event of my death wihout leaving any eligible family member for receiving pension
**Certified that I have no family as defined in para 2 (vii)of the Employees' Pension Scheme, 1995 and should I acquire a
family hereafter I shall furnish particulars thereon in above form.
Relationship with the member Date Of Birth Name and Address of Nominee
Name and address of the Factory/
Establishment or rubber stamp thereof
Designation
Signature of the employer or the other
authorized Officers of the establishment
Place :
Date :
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 got confirmed by him/her.
CERTIFICATE BY EMPLOYER
Signature or thumb impression of the Subscriber *strike out whichever is not applicable
Date :
(For Unexempted/ exempted Establishments)
(Paragraph 33 and 61(1) of the Employees ' Provident Fund Scheme, 1952 &
Paragraph 18of the Employees 'Pension Scheme 1995 )
Declaration and Nomination Form under the Employees' Provident Funds & Employess' Pension Scheme
1. Name 2. Father's / Husband Name
3. Date Of Birth 4. Sex
5. Marital Status 6. Account No.
7. E Mail Address 8. Phone No.
9. Address
Permanent
Temporary
I hereby nominate the person(s)/cancel the nomination made by me previously and nominate the person(s) , mention
below receive the amount standing to my credit in the Employee' Provident Fund , in the event of my Death
PART A (EPF)
Name of the
nominee/nominee's
Address Nominee's
relationship with
the member
Date Of
Birth
Total Amount or
Share of
accumulation in
Provident Fund
to be paid to
each nominee
If the nominee is minor
,name & relationship &
address of the guardian
who may receive the
amount during the
NOMINATION AND DECLARATION FORM
E/E3, HATIARA ROAD,SNEHLATA APARTMENT-C2,KOLKATA,TWENTY FOUR PGS NORTH,WEST BENGAL,700059
E/E3, HATIARA ROAD,SNEHLATA APARTMENT-C2,KOLKATA,TWENTY FOUR PGS NORTH,WEST BENGAL,700059
WB/PRB/0053862/000/0000005
FORM2 (Revised)
ABHISHEK PANDEY
04-Dec-1988
UNMARRIED
RAJENDRA PRASAD PANDEY
MALE
919804150170 abhisheksrk18@gmail.com
,,,,,
E/E3, HATIARA
ROAD,SNEHLATA
APARTMENT-C2,KOLKATA,T
WENTY FOUR PGS
NORTH,WEST
BENGAL,700059
16-Aug-1968 100 MAMTA PANDEY DEPENDENT MOTHER
*Cettified that i have no family as defined in para2 (g) of the Employees' Provident Fund Scheme,1952 and
should I acquire a familly hereafter the above nomination should be deemed as cancelled.
*strike out whichever is not applicable Signature or thumb impression of the Subscriber
* Certified that my father / mother is / are dependent upon me.
PART B (EPS)(Para 18)
I hereby furnish below particulars of the members of my family who would be eligible receive
widow/children pension in the event of my death
Sl.
No
1.
Name and Address of the family member Date Of Birth
4
Relationship with
member
5
Address
3
Name
2
1
I hereby nominate the following person for receving the monthly widow pension (admissible under para 16 2(a)(i)(ii) in the
event of my death wihout leaving any eligible family member for receiving pension
**Certified that I have no family as defined in para 2 (vii)of the Employees' Pension Scheme, 1995 and should I acquire a
family hereafter I shall furnish particulars thereon in above form.
Relationship with the member Date Of Birth Name and Address of Nominee
MAMTA PANDEY,E/E3, HATIARA ROAD,SNEHLATA
APARTMENT-C2,KOLKATA,TWENTY FOUR PGS NORTH,WEST
16-Aug-1968 DEPENDENT MOTHER
Name and address of the Factory/
Establishment or rubber stamp thereof
Designation
Signature of the employer or the other
authorized Officers of the establishment
Place :
Date :
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 got confirmed by him/her.
CERTIFICATE BY EMPLOYER
Signature or thumb impression of the Subscriber *strike out whichever is not applicable
Date :
(For Unexempted/ exempted Establishments)
(Paragraph 33 and 61(1) of the Employees ' Provident Fund Scheme, 1952 &
Paragraph 18of the Employees 'Pension Scheme 1995 )
Declaration and Nomination Form under the Employees' Provident Funds & Employess' Pension Scheme
1. Name 2. Father's / Husband Name
3. Date Of Birth 4. Sex
5. Marital Status 6. Account No.
7. E Mail Address 8. Phone No.
9. Address
Permanent
Temporary
I hereby nominate the person(s)/cancel the nomination made by me previously and nominate the person(s) , mention
below receive the amount standing to my credit in the Employee' Provident Fund , in the event of my Death
PART A (EPF)
Name of the
nominee/nominee's
Address Nominee's
relationship with
the member
Date Of
Birth
Total Amount or
Share of
accumulation in
Provident Fund
to be paid to
each nominee
If the nominee is minor
,name & relationship &
address of the guardian
who may receive the
amount during the
NOMINATION AND DECLARATION FORM
19D/H/19-GOABAGAN STREET,KOLKATA,KOLKATA,KOLKATA,WEST BENGAL,700006
19D/H/19-GOABAGAN STREET,KOLKATA,KOLKATA,KOLKATA,WEST BENGAL,700006
WB/PRB/0053862/000/0000006
FORM2 (Revised)
AMIT SHARMA
03-May-1976
MARRIED
SAMBHU PROSAD SHARMA
MALE
9830914059 sharma904@gmail.com
,,,,,
19D/H/19-GOABAGAN
STREET,KOLKATA,KOLKATA,
KOLKATA,WEST
BENGAL,700006
05-Dec-1979 50 PREM LATA SHARMA WIFE
,,,,,
19D/H/19-GOABAGAN
STREET,KOLKATA,KOLKATA,
KOLKATA,WEST
BENGAL,700006
04-Nov-1999 50 RISHIKA SHARMA DAUGHTER
*Cettified that i have no family as defined in para2 (g) of the Employees' Provident Fund Scheme,1952 and
should I acquire a familly hereafter the above nomination should be deemed as cancelled.
*strike out whichever is not applicable Signature or thumb impression of the Subscriber
* Certified that my father / mother is / are dependent upon me.
PART B (EPS)(Para 18)
I hereby furnish below particulars of the members of my family who would be eligible receive
widow/children pension in the event of my death
Sl.
No
1.
Name and Address of the family member Date Of Birth
4
Relationship with
member
5
Address
3
Name
2
19D/H/19-GOABAGAN
STREET,KOLKATA,KOLKATA,,700006
1 PREM LATA SHARMA 05-Dec-1979 WIFE
19D/H/19-GOABAGAN
STREET,KOLKATA,KOLKATA,WEST
2 RISHIKA SHARMA 04-Nov-1999 DAUGHTER
I hereby nominate the following person for receving the monthly widow pension (admissible under para 16 2(a)(i)(ii) in the
event of my death wihout leaving any eligible family member for receiving pension
**Certified that I have no family as defined in para 2 (vii)of the Employees' Pension Scheme, 1995 and should I acquire a
family hereafter I shall furnish particulars thereon in above form.
Relationship with the member Date Of Birth Name and Address of Nominee
Name and address of the Factory/
Establishment or rubber stamp thereof
Designation
Signature of the employer or the other
authorized Officers of the establishment
Place :
Date :
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 got confirmed by him/her.
CERTIFICATE BY EMPLOYER
Signature or thumb impression of the Subscriber *strike out whichever is not applicable
Date :
(For Unexempted/ exempted Establishments)
(Paragraph 33 and 61(1) of the Employees ' Provident Fund Scheme, 1952 &
Paragraph 18of the Employees 'Pension Scheme 1995 )
Declaration and Nomination Form under the Employees' Provident Funds & Employess' Pension Scheme
1. Name 2. Father's / Husband Name
3. Date Of Birth 4. Sex
5. Marital Status 6. Account No.
7. E Mail Address 8. Phone No.
9. Address
Permanent
Temporary
I hereby nominate the person(s)/cancel the nomination made by me previously and nominate the person(s) , mention
below receive the amount standing to my credit in the Employee' Provident Fund , in the event of my Death
PART A (EPF)
Name of the
nominee/nominee's
Address Nominee's
relationship with
the member
Date Of
Birth
Total Amount or
Share of
accumulation in
Provident Fund
to be paid to
each nominee
If the nominee is minor
,name & relationship &
address of the guardian
who may receive the
amount during the
NOMINATION AND DECLARATION FORM
LANGOLPARA (MANASHA MANDIR GOLI),GORKHARA,SONARPUR,SOUTH 24 PGS,WEST BENGAL,700150
LANGOLPARA (MANASHA MANDIR GOLI),GORKHARA,SONARPUR,SOUTH 24 PGS,WEST BENGAL,700150
WB/PRB/0053862/000/0000007
FORM2 (Revised)
ANKAN CHOUDHURY
07-Nov-1977
MARRIED
ANGSHU MOHAN CHOWDHURY
MALE
9433095870 ankan1111@yahoo.com
,,,,,
LANGOLPARA (MANASHA
MANDIR
GOLI),GORKHARA,SONARPU
R,SOUTH24 PGS,WEST
BENGAL,700150
02-Jan-1951 25 ANGSHU MOHAN
CHOUDHURY
DEPENDENT FATHER
,,,,,
LANGOLPARA (MANASHA
MANDIR
GOLI),GORKHARA,SONARPU
R,SOUTH24 PGS,WEST
BENGAL,700150
17-Mar-1958 25 CHHANDA
CHOUDHURY
DEPENDENT MOTHER
,,,,,
LANGOLPARA (MANASHA
MANDIR
GOLI),GORKHARA,SONARPU
R,SOUTH24 PGS,WEST
BENGAL,700150
09-Feb-1982 25 TANIA CHOUDHURY WIFE
,,,,,
LANGOLPARA (MANASHA
MANDIR
GOLI),GORKHARA,SONARPU
R,SOUTH24 PGS,WEST
BENGAL,700150
28-Nov-2013 25 ARSHIYA
CHOUDHURY
DAUGHTER
*Cettified that i have no family as defined in para2 (g) of the Employees' Provident Fund Scheme,1952 and
should I acquire a familly hereafter the above nomination should be deemed as cancelled.
*strike out whichever is not applicable Signature or thumb impression of the Subscriber
* Certified that my father / mother is / are dependent upon me.
PART B (EPS)(Para 18)
I hereby furnish below particulars of the members of my family who would be eligible receive
widow/children pension in the event of my death
Sl.
No
1.
Name and Address of the family member Date Of Birth
4
Relationship with
member
5
Address
3
Name
2
LANGOLPARA (MANASHA MANDIR
GOLI),SONARPUR,SOUTH24
1 TANIA CHOUDHURY 09-Feb-1982 WIFE
LANGOLPARA (MANASHA MANDIR
GOLI),SONARPUR,SOUTH24
2 ARSHIYA CHOUDHURY 28-Nov-2013 DAUGHTER
I hereby nominate the following person for receving the monthly widow pension (admissible under para 16 2(a)(i)(ii) in the
event of my death wihout leaving any eligible family member for receiving pension
**Certified that I have no family as defined in para 2 (vii)of the Employees' Pension Scheme, 1995 and should I acquire a
family hereafter I shall furnish particulars thereon in above form.
Relationship with the member Date Of Birth Name and Address of Nominee
Name and address of the Factory/
Establishment or rubber stamp thereof
Designation
Signature of the employer or the other
authorized Officers of the establishment
Place :
Date :
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 got confirmed by him/her.
CERTIFICATE BY EMPLOYER
Signature or thumb impression of the Subscriber *strike out whichever is not applicable
Date :
(For Unexempted/ exempted Establishments)
(Paragraph 33 and 61(1) of the Employees ' Provident Fund Scheme, 1952 &
Paragraph 18of the Employees 'Pension Scheme 1995 )
Declaration and Nomination Form under the Employees' Provident Funds & Employess' Pension Scheme
1. Name 2. Father's / Husband Name
3. Date Of Birth 4. Sex
5. Marital Status 6. Account No.
7. E Mail Address 8. Phone No.
9. Address
Permanent
Temporary
I hereby nominate the person(s)/cancel the nomination made by me previously and nominate the person(s) , mention
below receive the amount standing to my credit in the Employee' Provident Fund , in the event of my Death
PART A (EPF)
Name of the
nominee/nominee's
Address Nominee's
relationship with
the member
Date Of
Birth
Total Amount or
Share of
accumulation in
Provident Fund
to be paid to
each nominee
If the nominee is minor
,name & relationship &
address of the guardian
who may receive the
amount during the
NOMINATION AND DECLARATION FORM
SHYAM CHAND ROAD,NO-9, SANTIPUR,,NADIA,WEST BENGAL,741404
SHYAM CHAND ROAD,NO-9, SANTIPUR,,NADIA,WEST BENGAL,741404
WB/PRB/0053862/000/0000008
FORM2 (Revised)
ARINDAM MUKHERJEE
10-Feb-1978
MARRIED
ASHOK MUKHERJEE
MALE
,,,,,
SHYAM CHAND ROAD,NO-9,
SANTIPUR,,NADIA,WEST
BENGAL,741404
05-Feb-1984 100 SASWATI
MUKHERJEE
WIFE
*Cettified that i have no family as defined in para2 (g) of the Employees' Provident Fund Scheme,1952 and
should I acquire a familly hereafter the above nomination should be deemed as cancelled.
*strike out whichever is not applicable Signature or thumb impression of the Subscriber
* Certified that my father / mother is / are dependent upon me.
PART B (EPS)(Para 18)
I hereby furnish below particulars of the members of my family who would be eligible receive
widow/children pension in the event of my death
Sl.
No
1.
Name and Address of the family member Date Of Birth
4
Relationship with
member
5
Address
3
Name
2
SHYAM CHAND ROAD,,NADIA,,741404 1 SASWATI MUKHERJEE 05-Feb-1984 WIFE
I hereby nominate the following person for receving the monthly widow pension (admissible under para 16 2(a)(i)(ii) in the
event of my death wihout leaving any eligible family member for receiving pension
**Certified that I have no family as defined in para 2 (vii)of the Employees' Pension Scheme, 1995 and should I acquire a
family hereafter I shall furnish particulars thereon in above form.
Relationship with the member Date Of Birth Name and Address of Nominee
Name and address of the Factory/
Establishment or rubber stamp thereof
Designation
Signature of the employer or the other
authorized Officers of the establishment
Place :
Date :
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 got confirmed by him/her.
CERTIFICATE BY EMPLOYER
Signature or thumb impression of the Subscriber *strike out whichever is not applicable
Date :
(For Unexempted/ exempted Establishments)
(Paragraph 33 and 61(1) of the Employees ' Provident Fund Scheme, 1952 &
Paragraph 18of the Employees 'Pension Scheme 1995 )
Declaration and Nomination Form under the Employees' Provident Funds & Employess' Pension Scheme
1. Name 2. Father's / Husband Name
3. Date Of Birth 4. Sex
5. Marital Status 6. Account No.
7. E Mail Address 8. Phone No.
9. Address
Permanent
Temporary
I hereby nominate the person(s)/cancel the nomination made by me previously and nominate the person(s) , mention
below receive the amount standing to my credit in the Employee' Provident Fund , in the event of my Death
PART A (EPF)
Name of the
nominee/nominee's
Address Nominee's
relationship with
the member
Date Of
Birth
Total Amount or
Share of
accumulation in
Provident Fund
to be paid to
each nominee
If the nominee is minor
,name & relationship &
address of the guardian
who may receive the
amount during the
NOMINATION AND DECLARATION FORM
68(113) JAFFARPUR,6TH LANE,PO-NONA CHANDANPUKUR,BARRACKPUR,24 PGS NORTH,WEST BENGAL,700122
68(113) JAFFARPUR,6TH LANE,PO-NONA CHANDANPUKUR,BARRACKPUR,24 PGS NORTH,WEST BENGAL,700122
WB/PRB/0053862/000/0000009
FORM2 (Revised)
ARUP GHOSHAL
17-Jan-1963
MARRIED
AMRITA LAL GHOSHAL
MALE
91 arupghosal68@gmail.com
,,,,,
68(113) JAFFARPUR,6TH
LANE,PO-NONA
CHANDANPUKUR,BARRACK
PUR,24 PGS NORTH,WEST
BENGAL,700122
05-May-1970 70 KRISHNA GHOSHAL WIFE
,,,,,
68(113) JAFFARPUR,6TH
LANE,PO-NONA
CHANDANPUKUR,BARRACK
PUR,24 PGS NORTH,WEST
BENGAL,700122
22-Dec-1999 30 ARANITA GHOSHAL DAUGHTER
*Cettified that i have no family as defined in para2 (g) of the Employees' Provident Fund Scheme,1952 and
should I acquire a familly hereafter the above nomination should be deemed as cancelled.
*strike out whichever is not applicable Signature or thumb impression of the Subscriber
* Certified that my father / mother is / are dependent upon me.
PART B (EPS)(Para 18)
I hereby furnish below particulars of the members of my family who would be eligible receive
widow/children pension in the event of my death
Sl.
No
1.
Name and Address of the family member Date Of Birth
4
Relationship with
member
5
Address
3
Name
2
68(113) JAFFARPUR,6TH
LANE,BARRACKPUR,24 PGS
1 KRISHNA GHOSHAL 05-May-1970 WIFE
68(113) JAFFARPUR,6TH
LANE,BARRACKPUR,24 PGS
2 ARANITA GHOSHAL 22-Dec-1999 DAUGHTER
I hereby nominate the following person for receving the monthly widow pension (admissible under para 16 2(a)(i)(ii) in the
event of my death wihout leaving any eligible family member for receiving pension
**Certified that I have no family as defined in para 2 (vii)of the Employees' Pension Scheme, 1995 and should I acquire a
family hereafter I shall furnish particulars thereon in above form.
Relationship with the member Date Of Birth Name and Address of Nominee
Name and address of the Factory/
Establishment or rubber stamp thereof
Designation
Signature of the employer or the other
authorized Officers of the establishment
Place :
Date :
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 got confirmed by him/her.
CERTIFICATE BY EMPLOYER
Signature or thumb impression of the Subscriber *strike out whichever is not applicable
Date :