.Ale - Onboarding Composite Declaration Form 11 - V1

DocuSign Envelope ID: D299ADBE-5DF6-4B88-9A98-5EC2290CAA01
www.epfindia.gov.in
Composite Declaration Form-11
(To be retained by the employer for future reference)
EMPLOYEES’ PROVIDENT FUND ORGANISATION
Employees’ Provident Funds Scheme, 1952 (Paragraph 34 & 57) &
Employees’ Pension Scheme, 1995 (Paragraph 24)
(Declaration by a person taking up employment in any establishment on which EPF Scheme, 1952 and / or EPS, 1995 is applicable)
1 Name Alexchander .
Father's Name
2 Kuzhanthai Raj ( Father )
Spouse's Name
3 Date of Birth :(DD/MM/YYYY) 03/04/1998
4 Gender :(Male/Female/Transgender) Male
Marital Status Single
5 :(Married/Unmarried/Widow/Divorcee)
MBA
(a) Qualification :
6 (b) Email ID : [email protected]
(c) Mobile No : 7448459891
Present employment details:
7 Date of joining in the current 28/02/2023
establishment(DD/MM/YYYY)
KYC Details: (attach self-attested copies of following KYC's)
a) Bank Account No. : 152901000045527
IFSC Code of the branch : IOBA0001529
8 Employee Name as per Bank : Alexchander .
b) AADHAR Number 702951199288
Employee Name as per Aadhar : Alexchander .
c) Permanent Account Number (PAN), if available CWOPA7694C
Employee Name as per PAN : Alexchander .
Whether earlier a member of Employee’s Provident
9 Yes
Fund Scheme, 1952
Whether earlier a member of employee’s Pension
10 Yes
Scheme, 1995
Previous employment details: [if Yes to 9 AND/OR 10 above] -- Un-exempted
Establishment Universal EPF Account Date of Date of Whether Scheme PPO Non
Name & Account Number Joining : Exit Withdrawn Certificate Number Contributory
Address Number (DD/MM/ :(DD/MM/ EPF & EPS No. (if issued) (if issued) Period (NCP)
YYYY) YYYY) Amount Days
PVR PRIYA 101343437959 . 09/03/2020 14/08/2020
No
VILLAGE
ROADSHOW
11
Previous employment details: [if Yes to 9 AND/OR 10 above] – For Exempted Trusts
Name & Address Member EPS A/c Date of Date of Exit Whether Scheme Non
of the Trust UAN Number Joining (DD/MM/Y Withdrawn PF Certificate Contributory
(DD/MM/Y YYY) Amount No. (if issued) Period (NCP)
YYY) Days
12
13 a) International Worker No
b) If Yes, state country of origin (India / Name of the Country
c) Passport No.
d) Validity of Passport [(DD/MM/YYYY) to (DD/MM/YYYY)]
DocuSign Envelope ID: D299ADBE-5DF6-4B88-9A98-5EC2290CAA01
UNDERTAKING
1. Certified that the particulars are true to the best of my knowledge.

2. I authorize EPFO to use my Adhar for verification/authentication/e-KYC purpose for service delivery.
3. Kindly transfer the funds and service details, if applicable, from the previous PF account as declared above to the
present P.F. Account as I am Aadhar verified employee in my previous PF Account.
4. In case of changes in above details, the same will be intimated to employer at the earliest.
Date : 24 February 2023 Signature of Member

Place : Bangalore
DECLARATION BY PRESENT EMPLOYER
Alexchander . 28/02/2023
A. The member Mr/Ms/Mrs ………………………………………………………. has joined on ...................................... and has been
101343437959
allotted PF No. ……………………………………………………………..and UAN…………………………………………………………………………..
B. In case the person was earlier not a member of EPF Scheme, 1952 and EPS, 1995:
• 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/e-Sign
C. In case the person was earlier not a member of EPF Scheme, 1952 and EPS, 1995:
• Please Tick the Appropriate Option:

The KYC details of the above member in the UAN database have been approved with E-
Sign/Digital Signature Certificate and tranfer request has been genereated on portal.
The previous Account of the member is not Aadhar Verified and hence physical trasnfer form
shall be intiatied.
Date : Signature of Employer with Seal of the

Establishment
*Auto transfer of previous PF account would be possible in respect of Aadhar verified employees only. Other employees are
requested to file physical claim (Form-13) for transfer of account from the previous establishment.

.Ale - Onboarding Composite Declaration Form 11 - V1

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DocuSign Envelope ID: D299ADBE-5DF6-4B88-9A98-5EC2290CAA01

1. Certified that the particulars are true to the best of my knowledge.

Date : 24 February 2023 Signature of Member

DECLARATION BY PRESENT EMPLOYER

• Please Tick the Appropriate Option:

• Please Tick the Appropriate Option:

Date : Signature of Employer with Seal of the

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