Welcome Onboard!

�
We are all really excited to welcome you to our team!

To make your day one very exciting, smoother, hassle free and less boring we

request you to help us in filling these mandatory forms.

Instructions:

1. Please fill all the required information in the below forms and these are
mandatory.
2. In-case of any doubts or clarity required kindly refer the attached sample
forms provided.
3. Kindly provide signature(s) next to in all the required spaces.
4. This form can be filled digitally via any PDF viewer or editor. However,
Adobe Acrobat is preferred to fill this form as you can sign it digitally as
well.
 PERSONAL INFORMATION
*FIRST NAME : MAHESH
MIDDLE NAME :
*LAST NAME : C
DATE OF JOINING: 04-Dec-2023 EMPLOYEMENT NUMBER: 21010560
DESIGNATION: SENIOR ANALYST, SUPPLY CHAIN PROJECTS DEPARTMENT: CORPORATE SERVICES
CURRENT ADDRESS: NO 4 HARI NILAYA, 1ST CROSS, 2ND BLOCK, AKSHAYA NAGAR, TC PALYA MAIN ROAD DOORAVANINAGAR POST, BANGALORE

STATE: KARNATAKA PINCODE: 560016

PERMANENT NO 4 HARI NILAYA, 1ST CROSS, 2ND BLOCK, AKSHAYA NAGAR, TC PALYA MAIN ROAD DOORAVANINAGAR POST, BANGALORE

ADDRESS: STATE: KARNATAKA PINCODE: 560016

DATE OF BIRTH: 01-Mar-1994 TELEPHONE NUMBER: 8660078757
PERSONAL EMAIL ID: [email protected] MOBILE NUMBER: 9945391415
PAN NUMBER: DDFPM7255A AADHAAR NUMBER: 270791008394
PASSPORT / VOTER-ID / DRIVING LICENSE NUMBER: KA53 20130039434
GENDER: Male FATHER'S NAME: ____________________________
CHANDRASHEKAR

DISABILITY: NOT DISABLED

(Refer Equal Opportunity Policy)
MARITAL STATUS: Married

BLOOD GROUP: _______

B +ve MAHESH C
EMPLOYEE NAME AS PER AADHAR:____________________________
EMERGENCY CONTACT DETAILS
NAME OF THE PERSON (FAMILY/ LEGAL GUARDIAN): HEMAVATHI B
LANGUAGE OF CONTACT PERSON: KANNADA RELATIONSHIP: SPOUSE
MOBILE NUMBER: 9632294145 TELEPHONE NUMBER: 9902744453
ADDRESS OF CONTACT PERSON: NO 4 HARI NILAYA, 1ST CROSS, 2ND BLOCK, AKSHAYA NAGAR, TC PALYA MAIN ROAD DOORAVANINAGAR POST, BANGALORE
STATE: KARNATAKA PINCODE: 560016

DECLARATION AND AUTHORIZATION

I hereby confirm and declare that all the information as stated above in the employee data enrollment application form
is true and correct. I further confirm to notify the Company within 15 days of any changes to the above provided
information. I also confirm and declare that I or my legal successors/ heirs shall not hold the Company responsible for
any concerns which may arise out of the above information provided, if found to be untrue.
ACKNOWLEDGED AND SUBMITTED BY
DATE: 04-Dec-2023 PLACE: BANGALORE (city/village name)
EMPLOYEE NAME: MAHESH C

SIGNATURE:
BANK DETAILS (This is for Payroll Purpose)

NAME AS PER BANK : MAHESH C

DATE OF JOINING : 04-Dec-2023

BANK NAME : ICICI BANK

IFSC CODE : ICIC0002330

BANK ACCOUNT NO : 004701616516

BANK CITY : BANGALORE

BRANCH NAME : RAMAMURTHY NAGAR

✔ I hereby declare that all the above information is correct and accurate.

NAME: MAHESH C

DATE: 04-Dec-2023 SIGNATURE:

 CONFIDENTIAL INFORMATION & INVENTIONS AGREEMENT

THIS AGREEMENT IS NOT AN EMPLOYMENT CONTRACT, EITHER EXPRESS OR IMPLIED

MAHESH C
This Confidential Information Agreement (this "Agreement") is entered into as of the date set forth below by ______________________________
("you” or “your"). In consideration of your employment by _Molex India Business
_ Services Pvt Ltd or any of its subsidiaries (your employer referred to
as, the "Company"), and for other good and valuable consideration, the receipt and sufficiency of which is hereby acknowledged, you hereby agree
as follows:
1. Maintaining Confidential Information.a. Company Information.

(i) For purposes of this Agreement, "Confidential Information" means any trade secrets, confidential or proprietary knowledge, data or other information of
the Company, any of its affiliates or any third party for which the Company or any of its affiliates has an obligation regarding the protection of such information,
that the Company or any of its affiliates may designate or otherwise treat as confidential, including without limitation information related to products, processes,
know-how, designs, formulas, developmental or experimental work, computer programs, data bases, other original works of authorship, customer lists,
business relationships, targeted potential customers or business relationships (including potential acquisition targets, divestitures), marketing, pricing, business
plans, strategies, financial information or other subject matter pertaining to any business of the Company or any of its affiliates, clients, vendors, business
partners, suppliers, consultants or licensees or other third parties having a business or contractual relationship with the Company or any of its affiliates.
(ii) At all times during your employment with the Company and thereafter, you will: (a) hold all Confidential Information in the strictest confidence, and (b) not
use or disclose to any person or entity any Confidential Information, except (1) for the benefit of the Company and in the course of your duties to the Company
as an employee of the Company, (2) as required by applicable law or regulation, or (3) as specifically permitted in writing by the Company. If an item of
Confidential Information becomes permanently available to the general public without restriction, through no wrongful act or omission of yours, then you will
no longer have the obligation to maintain the confidentiality and secrecy of such item. In the case of any disclosure compelled by court order or governmental
subpoena, you will provide the Company with prompt written notice of such order or subpoena. Please also see the Notice of Defend Trade Secrets Act
Immunity policy on your Company’s intra-net site or bulletin board.
b. Representations Regarding Former Employer Information. You represent that the performance of this Agreement will not breach or conflict with any
agreement or obligation to keep in confidence any information acquired by you before your employment by the Company. You have not entered into, and will
not enter into, any oral or written agreement in conflict with this Agreement. Further, you will not, during your employment with the Company, improperly use
or disclose any proprietary information or trade secrets of your former or concurrent employers or other parties to which you have confidentiality obligations
(whether or not such obligations are specifically expressed in writing), and will not bring onto the premises of the Company any unpublished document or any
property belonging to your former or concurrent employers or other parties to which you have confidentiality obligations, unless consented to in writing by such
employers or other parties.
c. Third Party Information. The Company and its affiliates have received and in the future will receive from third parties their confidential or proprietary
information subject to a duty to maintain the confidentiality of such information and to use it only for certain limited purposes. You will, during the term of your
employment and thereafter, hold all such confidential or proprietary information of third parties in the strictest confidence and not disclose it to any person or
entity or use it in any manner, other than as permitted by the agreement with such third party.
2. Returning Company Documents. Upon termination of your employment with the Company or upon the Company’s request, you will deliver to the Company
(and will not keep in your possession or deliver to anyone else) any and all depictions of Confidential Information, whether in tangible or intangible form, and
all other property of the Company or any of its affiliates.
3. Notification to New Employer. You hereby consent to the Company notifying your subsequent employers and other third parties about your obligations
under this Agreement.
4. Further Assurances. Upon the Company’s request and without compensation, you will do all lawful acts, including the execution and delivery of documents
and the giving of testimony and oaths, that the Company deems reasonably necessary or useful in obtaining, sustaining, reissuing, extending and enforcing
any available registration and other protection or enforcement of Confidential Information or to carry out the terms of this Agreement.
5. Remedies Upon Breach. In the event of any breach or threatened breach of this Agreement by you, the Company will be entitled, if it so elects, to institute
and prosecute proceedings in any court of competent jurisdiction, either in law or in equity, to enjoin you from violating this Agreement, to enforce the specific
performance by you of this Agreement, and to obtain damages, but nothing herein contained shall be construed to prevent such remedy or combination of
remedies as the Company may elect to invoke. The failure of the Company to promptly institute legal action upon any breach of this Agreement will not
constitute a waiver of that or any other breach of this Agreement.
6. Policies. The obligations set forth in the Company’s policies and procedures from time to time, including (without limitation) the Company’s Code of Conduct,
as such policies and procedures may be amended or revised from time to time, will be unaffected by this Agreement, and such obligations will be in addition
to those set forth herein. ‘
7. Inventions and Assignment. You acknowledge and agree that any inventions, copyrights, patents, trademarks, service marks, source codes, software,
design rights, trade names, logos, corporate names, know how, work product, improvement or discovery, whether or not patentable, that you conceive, create,
develop, make, or reduce to practice, whether alone or in conjunction with others during your employment by the Company (including during any period of
employment with the Company before you sign this agreement) or within six months immediately thereafter are works made for hire (hereinafter referred to as
“Inventions”). As such, you hereby assign and agree to assign to the Company all of your right, title and interest in all Inventions on a perpetual, worldwide
and royalty free basis. You agree to disclose all Inventions to the Company, regardless whether you assert such inventions to be nonassignable, and will fully
cooperate with the Company to protect the Company’s interests in and rights to such Inventions (including, but not limited to, providing reasonable assistance
1
in securing patent protection and/or copyright registrations and executing all documents reasonably requested by the Company, whether those requests occur
before or after the end of your employment).
Any assignment of Inventions pursuant to this Agreement includes all rights of paternity, integrity, modification, disclosure and withdrawal, and any other similar
rights in perpetuity throughout the world that may be known as or referred to as ‘moral rights’ (“Moral Rights”). To the extent that Moral Rights cannot be
assigned under applicable law, you hereby waive and agree not to enforce any and all Moral rights, including, without limitation, any limitation on subsequent
modification, to the extent permitted under applicable law.
Notwithstanding the provisions of Section 19(4) of the Copyright Act, 1957, such assignment in so far as it relates to copyrightable material shall not lapse nor
the rights transferred therein revert to you, even if the Company does not exercise the rights under the assignment within a period of one year from the date of
assignment.
You understand that this provision does not require you to assign any invention for which no equipment, supplies, facility, or Confidential Information of the
Company was used and that was developed entirely on your own time and that: i) does not relate (at the time the invention was conceived or reduced to
practice) to the Company’s business, its actual or demonstrably anticipated research or development, or ii) does not result from any work you performed for
the Company.
8. Securities Law Compliance. You agree to comply at all times with U.S. securities laws and hereby acknowledge that U.S. securities laws prohibit under
certain circumstances any person with material, non-public information about an issuer of securities from purchasing or selling securities of such issuer or,
subject to certain limited exceptions, from communicating such information to any other person.
9. General Provisions.
a. Governing Law; Consent to Jurisdiction. This Agreement will be governed by the laws of India and shall be binding on and enforceable against your
heirs, executors, administrators and legal representatives and the assignees of any Inventions. You hereby consent to the exclusive personal jurisdiction of
the courts located in [Mumbai/Bangalore] for any lawsuit filed by or against you under this Agreement or in connection with any Confidential Information.
Nothing in this provision shall prohibit the Company from bringing an action to enforce this Agreement or any judgment obtained by the Company in connection
with this Agreement in any other jurisdiction.
b. Entire Agreement. Except as specifically set out above (including, for example, Section 6), this Agreement sets forth the entire agreement and
understanding between the Company and you, and supersedes all prior discussions and agreements between you and the Company, relating to the subject
matter of this Agreement. No modification of or amendment to this Agreement, or any waiver of any rights under this Agreement, will be effective unless in
writing signed by the party against whom such modification, amendment or waiver is to be enforced. This Agreement does not constitute a contract for a
specific term of employment, and does not limit the Company's right to terminate your employment at any time and for any reason, with or without cause, or in
compliance with any applicable collective bargaining agreement. No subsequent change or changes in your duties, salary or compensation, or termination of
your employment will affect the validity or scope of this Agreement or confer any rights upon you.
c. Severability; Survival. If one or more of the provisions of this Agreement are deemed void by law, then the remaining provisions will continue in full force
and effect. Except as otherwise set forth in this Agreement, your obligations under this Agreement shall survive the termination of your employment with the
Company.
d. Attorneys' Fees. In the event of any litigation, or other proceeding concerning any controversy, claim or dispute between the parties hereto, arising out of
or relating to this Agreement, the breach hereof or the interpretation hereof, the prevailing party will be entitled to recover from the other party reasonable
expenses, attorneys' fees, and costs incurred therein or in the enforcement or collection of any judgment or award rendered therein. The "prevailing party"
means the party determined by the court to have most nearly prevailed, even if such party did not prevail in all matters, not necessarily the party in whose
favor a judgment is rendered. Further, in the event of any breach by a party under this Agreement, such breaching party shall pay all the expenses and
attorneys' fees incurred by the other party in connection with such breach, whether or not any litigation is commenced.
e. Electronic Signature. This Agreement may be executed in one or more counterparts or duplicate originals, all of which taken together will constitute one
and the same agreement. Electronically executed versions or a signature page through the DocuSign, Inc. electronic signing system will be deemed the same
as an original executed signature page. At the request of the Company, you will promptly confirm all electronically executed versions of any signature page
by manually executing and delivering a duplicate original signature page.
IN WITNESS WHEREOF, this Agreement has been executed as of the date set forth below.

21010560
______________________________________________ ______________________________________________
(Employment Number) Employee Signature

04-Dec-2023
_______________________________________________ MAHESH C
______________________________________________
Date ( Date of Joining) Employee Name

2
 New Form No.11- Declaration Form
(To be retained by the employer for future reference)

EMPLOYEES PROVIDENT FUND ORGANIZATION Emp Numb:________________________

21010560
Employees provident funds scheme, 1952 (paragraph 34 & 57) & Molex India Business Services Pvt Ltd
Employees pension scheme 1995 (paragraph 24)
Company:

(Declaration by a person taking up employment in any establishment on which EPF Scheme, 1952 end /of EPS 1995 is applicable)
1 Name of the member MAHESH C
2 Father’s Name ( ) Spouse’s Name ( )
(Please Tick Whichever Is Applicable) CHANDRASHEKAR
3 Date of Birth (DD/MM/YYYY) 01-Mar-1994
4 Gender: (Male / Female /Transgender) Male
5 Marital Status (married /Unmarried /widow/divorce) Married
6 (a)Email ID: ____________________________
[email protected]
(b)Mobile No: 9945391415
7* Whether earlier a member of Employees ‘provident Fund Scheme 1952 Yes No
8* Whether earlier a member of Employees ‘Pension Scheme ,1995 Yes No
If response to any or both of (7) & (8) above is yes. MANDATORY FILL UP THE (COLUMN 9)
a) Universal Account Number(UAN) 101108044841
b) Previous PF a/c No AP HYD EST.CODE EXTN PF NO.
PYKRP17041770000010961
9 c) Date of exit from previous employment (DD/MM/YYY)
(company) 01-Dec-2023
d) Scheme Certificate No (if Issued ) (if applicable)

e) Pension Payment Order (PPO)No (if Issued) (if applicable)

a) International Worker: Yes No
b) If Yes , State Country Of Origin (India /Name of Other Country)
10
c) Passport No
d) Validity Of Passport (DD/MM/YYY) to(DD/MM/YYY) to
KYC Details: (attach Self attested copies of following KYCs) **
a) Bank Account No .& IFS code 004701616516 & ICIC0002330
11
b) AADHAR Number (12 Digit) 270791008394
c) Permanent Account Number (PAN),If available DDFPM7255A
UNDERTAKING
1) Certified that the Particulars are true to the best of my Knowledge
2) I authorize EPFO to use my Aadhar for verification / e KYC purpose for service delivery
3) Kindly transfer the funds and service details, if applicable if applicable, from the previous PF account as declared above to the
present P.F Account(The Transfer Would be possible only if the identified KYC details approved by previous employer has
been verified by present employer
4) In case of changes In above details the same Will be intimate to employer at the earliest
Date: 04-Dec-2023
Place: BANGALORE Signature of Member
DECLARATION BY PRESENT EMPLOYER
A) The member Mr./Ms./Mrs ………………..has joined on …………….and has been allotted PF Number……………………………….
B) In case person was earlier not a member of EPF Scheme ,1952 and EPS,1995
 (Post allotment of UAN ) The UAN Allotted for the member is…………..
 Please tick the Appropriate Option:
 The KYC details of the above member in the UAN database
 Have not been uploaded
 Have been uploaded but not approved
 Have been uploaded and approved with DSC
C) In case the person was earlier a member of EPF Scheme ,1952 and EPS, 1995:
 The above PF account number /UAN of the member as mentioned in (a) above has been tagged with his /her UAN/previous member ID as
declared by member
 Please Tick the Appropriate Option
 The KYC details of the above member in the UAN database have been approved with digital signature Certificate and transfer request
has been generated on portal.
 As the DSC of establishment are not registered With EPFO the member has been informed to file physical claim (Form13) for transfer
of funds from his previous establishment.
Date
Signature of Employer With seal of Establishment
 (FORM 2 REVISED)

NOMINATION AND DECLARATION FORM FOR UNEXEMPTED/EXEMPTED ESTABLISHMENTS

Declaration and Nomination Form under the Employees Provident Funds and Employees’ Pension Schemes
(Paragraph 33 and 61 (1) of the Employees Provident Fund Scheme 1952 and Paragraph 18 of the Employees
Pension Scheme 1995)

MAHESH C
1. Name (IN BLOCK LETTERS) : ____________________________________________________________________
Name Father’s / Husband’s Name Surname

Date of Birth : 01-Mar-1994

101108044841 (UAN Number)
2. ___________________ 3. Account No. ___________________

Married
4. *Sex: MALE/FEMALE/TRANSGENDER: Male
________________ 5. Marital Status ___________________________

NO 4 HARI NILAYA, 1ST CROSS, 2ND BLOCK, AKSHAYA NAGAR, TC PALYA MAIN ROAD DOORAVANINAGAR POST, BANGALORE
6. Address Permanent / Temporary: ___________________________________________________________________

PART – A (EPF)
I hereby nominate the person(s)/cancel the nomination made by me previously and nominate the person(s) mentioned below to
receive the amount standing to my credit in the Employees Provident Fund, in the event of my death.

If the nominee is minor

Name of the Address Nominee’s Date of Total amount or share of name and address of the
Nominee (s) relationship with Birth accumulations in guardian who may receive
the member Provident Funds to be the amount during the
paid to each nominee minority of the nominee

1 2 3 4 5 6
HEMAVATHI B - NO 4 HARI NILAYA, 1ST CROSS, 2ND BLOCK, AKSHAYA
NAGAR, TC PALYA MAIN ROAD DOORAVANINAGAR POST, BANGALORE SPOUSE 02-Mar-1995
100 %
%
%
%
%

1 *Certified that I have no family as defined in Para 2 (g) of the Employees Provident Fund Scheme
1952 and should I acquire a family hereafter the above nomination should be deemed as cancelled.

2. * Certified that my father/mother is/are dependent upon me.

Strike out whichever is not applicable Signature/or thumb impression

Of the subscriber

IMPORTANT NOTE:
A) IF YOU ARE MARRIED THEN YOU CAN NOMINATE SPOUSE & CHILDREN
B) IF YOU ARE UNMARRIED/SEPARATED/WIDOWED THEN YOU CAN NOMINATE PARENTS/CHILDREN
C) MARRIED CAN NOMINATE THEIR PARENTS, BUT THIS SHOULD BE GIVEN AFTER DATE OF MARRIAGE
 PART – (EPS)
Para 18
I hereby furnish below particulars of the members of my family who would be eligible to receive
Widow/Children Pension in the event of my premature death in service.

Sr. No Name & Address of the Family Member Age Relationship with the member

(1) (2) (3) (4)

1. Hemavathi B - No 4 Hari Nilaya, 1st cross, 2nd block, Akshaya Nagar, TC Palya, Ban - 16
27 SPOUSE
2.
3.
4.
5.
6.
7.
IMPORTANT NOTE: IF YOU ARE MARRIED THEN YOU CAN NOMINATE SPOUSE / CHILDREN,
IF SEPARATED/WIDOW THEN YOU CAN NOMINATE CHILDREN
IF YOU ARE UNMARRIED THEN LEAVE THE ABOVE & BELOW TABLES BLANK

IF NO SPOUSE & CHILDREN THEN FILL PARENT/S NAME (PREFERABLY MOTHER) IN THE BELOW TABLE

Certified that I have no family as defined in para 2 (vii) of the Employees’ Family Pension Scheme 1995 and
should I acquire a family hereafter I shall furnish Particulars there on in the above form.
I hereby nominate the following person for receiving the monthly widow pension (admissible under para 16 2
(a) (i) & (ii) in the event of my death without leaving any eligible family member for receiving pension.
Name and Address of the nominee Date of Birth Relationship with member

Signature or thumb impression of the subscriber

______________________________________________________________________________________
__________________

CERTIFICATE BY EMPLOYER

Certified that the above declaration and nomination has been signed / thumb impressed before me by
Shri / Smt./ Miss_____________________________________________________________ employed in my
establishment after he/she has read the entries / the entries have been read over to him/her by me and got
confirmed by him/her.

Date: _____________________ Signature of the employer or other authorized officer of the

Establishment

Place:
Name & address of the Factory /Establishment (Seal)
 GRATUITY

FORM–F
[See sub-Rule (1) of Rule 6]

Nomination
To Molex India Business Services Pvt Ltd

1. I, Shri / Shrimati / Kumari MAHESH C

_______________________________________________________
whose particulars are given in the statement below, hereby nominate the person(s) mentioned below to receive
the gratuity payable after my death as also the gratuity standing to my credit in the event of my death before
that amount has become payable, or having become payable has not been paid and direct that the said amount
of gratuity shall be paid in proportion indicated against the name(s) of the nominee(s).

2. I hereby certify that the person(s) mentioned is a /are member(s) of my family within the meaning of clause
(h) of Section 2 of the Payment of Gratuity Act, 1972.

3. I hereby declare that I have no family within the meaning of clause (h) of Section 2 of the said Act.

4. (a) My father/mother/parents is/are not dependent on me

(b) My husband’s father/mother/parents is/are not dependent on my husband.

5. I have excluded my husband from my family by a notice dated the ……………. to the Controlling Authority
in terms of the proviso to clause (h) of Section 2 of the said Act.

6. Nomination made herein invalidates my previous nomination.

NOMINEE(S)
Name in full with full Relationship with the Age of Proportion by which the gratuity
address of nominee(s): employee nominee: will be shared:
1 2 3 4
HEMAVATHI B - NO 4 HARI NILAYA, 1ST CROSS, 2ND BLOCK, AKSHAYA
NAGAR, TC PALYA MAIN ROAD DOORAVANINAGAR POST, BANGALORE SPOUSE 27 100 %
%
%
%
IMPORTANT NOTE:
A) IF YOU ARE MARRIED THEN YOU CAN NOMINATE SPOUSE & CHILDREN
B) IF YOU ARE UNMARRIED/SEPARATED/WIDOWED THEN YOU CAN NOMINATE MOTHER/CHILDREN/FATHER

STATEMENT
1. Name of employee in full : MAHESH C

2. Sex (Male/Female /Transgender) : Male

3. Religion :
4. Whether unmarried/married/widow/widower : Married
5. Department/Branch/Section where : _____________________________
CORPORATE SERVICES
employed
6. Post held with Ticket No. or Serial No. if any : 21010560 (Employment Number)
7. Date of appointment : 04-Dec-2023
8. Permanent address : NO 4 HARI NILAYA, 1ST CROSS, 2ND BLOCK, AKSHAYA NAGAR, TC PALYA MAIN ROAD DOORAVANINAGAR POST, BANGALORE

_
KARNATAKA 560016
Village Thana Sub-Division
Post Office District State

BANGALORE
Place: _______________
04-Dec-2023
Date: _______________ Signature/Thumb impression of the employee

Declaration by witnesses:
Nomination signed/thumb impressed
before me:

Name in full and full address of witnesses: Signature of witnesses:

1. 1.
2.
2.

BANGALORE
Place: ______________
04-Dec-2023
Date: _______________

IMPORTANT NOTE: WITNESS COULD BE ANYONE OTHER THAN YOU

 Leave Encashment

FORM No. 25
1[(See Rule 127)]

FORM OF NOMINATION

I hereby declare that in the event of my death before resuming

work, the balance of my pay due for the period of leave with wages
HEMAVATHI B
not availed of shall be paid to . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
WIFE
. . . . . . . . . . . . . . . . . . . who is my . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
and resides at, NO
. . . .4.HARI
. . . . .NILAYA,
. . . . . . .1ST
. . . CROSS,
. . . . . . . 2ND
. . . . BLOCK,
. . . . . . AKSHAYA NAGAR, TC PALYA

1. Witness . . . . . . . . . . . . . . .
Signature of Witness 1

2. Witness . . . . . . . . . . . . . . .
Signature of Witness 2

04-Dec-2023
Date . . . . . . . . . . . . . . . Signature or thumb impression of the Employee

IMPORTANT NOTE: WITNESS COULD BE ANYONE OTHER THAN YOU

 Accidental/Death Benefits- Beneficiary Nomination Form

Name of the Employee: MAHESH C

Employee ID: 21010560

BENEFICIARY DETAILS

I hereby nominate the following beneficiary/ies under:

Group Term Life Insurance/ Company provided Death Benefit:

Sl. No. Name & Address of the Beneficiary Relationship with % share of benefit
Insured (e.g. 50%/ 100%, etc)
HEMAVATHI B, NO 4 HARI NILAYA, 1ST CROSS, 2ND BLOCK, AKSHAYA NAGAR,
TC PALYA MAIN ROAD DOORAVANINAGAR POST, BANGALORE
SPOUSE 100 %
%
%
%

Group Personal Accident Insurance/ Accident Pay:

Sl. No. Name & Address of the Beneficiary Relationship with % share of benefit
Insured (e.g. 50%/ 100%, etc)
SPOUSE
HEMAVATHI B, NO 4 HARI NILAYA, 1ST CROSS, 2ND BLOCK, AKSHAYA NAGAR, TC PALYA MAIN ROAD DOORAVANINAGAR POST, BANGALORE 100 %
%
%
%

Terms:
- Insured/Covered employee may choose more than 1 nominee to claim the insured/covered amount
- The sum total of the % share of benefit shall be 100%
- If you choose only one nominee, the % share of benefit shall be 100% and keep other rows blank/ NA
- % Share Benefit: The claim amount shall be disbursed in the same proportion as declared
- If the nominee is a non-resident, the claim amount would be subject to relevant tax evaluation as per the
respective tax treaty/ international taxation and then paid. There could be a potential delay in the claim
settlement in case of non-resident nominees.

Date: 04-Dec-2023

Place: BANGALORE
……………………..
(Signature of the Employee)

IMPORTANT NOTE:
A) IF YOU ARE MARRIED THEN YOU CAN NOMINATE SPOUSE & CHILDREN
B) IF YOU ARE UNMARRIED/SEPARATED/WIDOWED THEN YOU CAN NOMINATE MOTHER/CHILDREN/FATHER
 ACKNOWLEDGEMENT & CONSENT
REGARDING NIGHT SHIFT WORK
To be used by women employees who work during the night shift or such shift(s) falling partly or wholly
between the hours of 8.00 PM to 6.00 AM.

I ______________________________ (employee name), having employee ID ______________ (employee

number), working in the _______________ (team/department name) and reporting to _____________
(supervisor name), do hereby accord voluntarily and of my own consent to work in the shift which may
extend into or fall partly or wholly between the hours of 8.00 PM to 6.00 AM.

I further declare that:

1. I am fully aware of the roles, responsibilities and duties assigned to the role I am working which
requires my presence in the organization during the time either extending into or falling partly or
wholly between the hours of 8.00 PM and 6.00 AM.
2. I was informed, made aware of and agreed to the fact that my role is fixed to the shift which extends
to or falls in the above referred timeline and that there is probability of no rotation of this shift due
to business reasons.
3. In regard to transportation, I confirm I am obliged as follows:
a. To inform the Supervisor and Travel Coordinator at least 2 hours prior in case of extension
of my shift beyond 8.00 PM.
b. To use the Company transport as assigned to me by the Company’s travel desk and follow
any required protocols including asking for security as necessary.
c. In case I chose for my own reasons to use personal transport, I confirm I am further obliged
as follows:
• to keep my supervisor or the Travel Coordinator informed by way of email of my
choice to use personal transport.
• I shall inform my supervisor on reaching my intended destination safely when
using a personal transport.
• I further confirm and agree that neither I nor my family members shall hold the
Company and its officers/employees responsible for any issues arising out of such
use such as motor vehicle accidents, safety issues, etc. and that I shall take adequate
safety measures when using private transport.
4. If at any time, I have concerns about this document or about my shift assignment (including whether
it is fixed or rotating) or hours of work, I confirm and agree that I will raise these promptly to my
supervisor or to Human Resources.

Date:_________________
Place:_________________

_________________________
Employee Signature
 Type of Document Sl.No Day one Onboarding Documentation Checklist Yes

1 Joining Forms
HR Documents ✔
2 Signed Appointment Letter
✔
3 Aadhaar Copy
✔
4 PAN Copy
✔
5 Specific Educational Qualification Certificate / Mark Sheet
Employee ✔
Documents Last Employer Relieving Letter or Resignation Acceptance Email /
6 ✔
Letter
7 Bank Account Details (Cancelled Cheque/Passbook copy) ✔
8 1 Passport size photo ✔
Additional ID Proof 9 Passport / Voter ID / Driving License ✔
Women in Night
10 Consent from Women employees working in Night Shift *if applicable
Shift

DATE: __________
04-Dec-2023
EMPLOYEE NAME: _____________________
MAHESH C

EMPLOYMENT NUMBER: ______________________________________________________

21010560

SIGNATURE: _____________________