child labour

Emp No

:

Mobile no :

Reg. No.____________

E-mail Id :

Employees’ Provident Funds Scheme, 1952
Form 19
(Refer to instruction)
1
 Name of the member in
BLOCK LETTERS
2

3

4



Father’s Name or
(Husband’s Name in case of married woman)
Name & Address of the Factory /
Establishment in which the member was employed
PF Account No.



5
6



__________________________________________________

___________________________________________

Date of Leaving Service

Reason for Leaving Service

7

__________________________________________________

__________________________________________________
RESIGNATION_____________________________________

Full Postal Address (in
BLOCK LETTERS)

SHRI / SMT / KUM ___________________________________
S/o / W/o / D/o

___________________________________

__________________________________________________
___________________________ PIN ___________________



8

Mode of remittance

a

By Postal Money Order at my Cost



b

By account payee cheque sent directly for credit to my
Saving Bank Account
(Scheduled Bank / Post
Office) under intimation to me Put a tick (
) in the box against the one opted
( ) To the address given against item No. 7
(

) Saving Bank Account No. ___________________________

Name of the Bank _____________________________________
Branch ______________________________________________
Full address of the branch _______________________________
_____________________________________________________
________________________MICR CODE ___________________
IFSC CODE ____________________________________________

(Advance Stamped Receipt Furnished)
Certified that the particulars are true to the best of my knowledge.
Date of Joining the Establishment



__________________________________________________
__________________________________________________

Date of Birth

Contribution for Current Financial Year