CONFIDENTIAL

A.Menarini India Private Limited.

A-101 Shapath IV, Opp. Karnavati Club, S.G.Highway, Ahmedabad – 380 015.
Tele. No. 079 – 40006300

EMPLOYMENT FORM

Kindly Paste Your

Passport Size

Photograph Here

Name:

ALL CAPITAL LETTER

To be filled by Personnel Department :

Location : Corporate Office / Field

Employee Code : ______________________ P. F A/c. No. : GJ / AHD / 28826 / _________________

Date of Joining : ___________________________ Designation : _______________________________

Project : __________________________________ Q. I. D : ____________________________________

Note : -

1. Please fill up the form in your own hand writing in CAPITAL LETTER. Please use  mark to
indicate the appropriate answer.

2. Use the last page / separate sheet of paper, wherever required.

3. Whenever any information given by you in this form changes. Please make sure that it is conveyed to the
Personnel Department in writing, at the earliest.
Page 1 of 7
 [1] - PERSONAL DATA: -

1. Full Name: -

{ Note : Write in this manner : First Name – Middle Name – Last Name }

2. Permanent Address: - Present Address: -

__________________________________ ______________________________________
__________________________________ ______________________________________
__________________________________ ______________________________________
__________________________________ ______________________________________
__________________________________ ______________________________________
__________________________________ ______________________________________
Pin Code [ ] [ ] [ ] [ ] [ ] [ ] Pin Code [ ] [ ] [ ] [ ] [ ] [ ]
Phone No. [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] Phone No. [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ]
Mobile No. [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] E Mail: _______________________________

- Home Town: __________________________________

3. Date of Birth: [ ] [ ] [ ][ ] [ ] [ ] [ ] [ ] Age (as on date) : _____________________

(Day) (Month) (Year)

4. Sex: [ ] Male [ ] Female

5. Pan Card:

6. Religion: Hinduism / Islam / Sikhism / Christianity / Any other (Specify) : ______________________

7. Nationality: [ ] Indian Any Other (Specify) : _______________

8. (A) Caste : __________________________________________________________________________

(B) Does it fall under schedule caste / tribe : [ ] Yes [ ] No

9. Identification Mark : ________________________________________________________________

10. Passport : Self : [ ] Yes [ ] No Spouse : [ ] Yes [ ] No

No. [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] No. [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ]

11. Health : -

(A) Height : Ft. : __________, Inch : _________, Cms. : ________, (B) Weight : ____________ (Kgs.)

(C) Vision : [ ] Normal [ ] Spectacles / Contact Lens

If Spectacles / contact lens number of : Left Eye : ____________ Right Eye : ______________

Page 2 of 7
(D) Physical Defects : ______________________________________________________________

(E) Any major illness : ( 1 ) Family : ___________________________________________________

( Past & Present ) ( 2 ) Self : ___________________________________________________

(F) Convicted any time ? Details : ___________________________________________________

(G) Do you own vehicle/s ? : [ ] Yes [ ] No [ ] No. of vehicles

Give details : ___________________________________________________

Mode of ownership : [ ] Self [ ] Company [ ] Spouse [ ] Child

Mode of purchase : [ ] Loan [ ] Other sources [ ] Outright purchase

(H) Accommodation : [ ] Your own [ ] On rent [ ] With parents / relatives

If own, mode of purchase : [ ] On Loan [ ] Other Sources [ ] Outright purchase

(I) Are there any factors which will keep you occupied after joining ( e. g. children’s education, -

housing problem, financial obligation etc. ) _____________________________________________

(J) What are your objectives in life ? What are you currently doing to achieve them ?
_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

[2] - (A) FAMILY PARTICULARS : -

Relationship Name Qualification Age Occupation

Father
Mother
Brother / Sister - 1
Brother / Sister - 2
Brother / Sister - 3
Brother / Sister - 4

(B) (1) Marital Status : [ ] Single [ ] Married [ ] Divorced

(2) Marriage Anniversary / Date : [ ][ ] [ ][ ] [ ][ ][ ][ ]

(Day) (Month) (Year)

(3) Name of spouse : ___________________________________________________

Page 3 of 7
 (4) Spouse’s Date of Birth : [ ][ ] [ ][ ] [ ][ ][ ][ ]
(Day) (Month) (Year)

(5) If employed, organization : ____________________________________________________

Position : ____________________________________________________

(6) No. of Children : ___________ [ ] Male [ ] Female

(Day) (Month) (Year)

1. __________________________ [ ][ ] [ ][ ] [ ][ ][ ][ ]

2. __________________________ [ ][ ] [ ][ ] [ ][ ][ ][ ]

3. __________________________ [ ][ ] [ ][ ] [ ][ ][ ][ ]

(7) Blood Group : Self _____, Spouse _____, Child 1_____, Child 2 ______, Child 3 _______.

[3] – LANGUAGE PROFICENCY : - ( List all languages know to you )

(1) Mother Tongue : _______________________________________________________________

(2) Languages Known ( Please  )

Read Speak Write

1. English [ ] [ ] [ ]

2. Hindi [ ] [ ] [ ]

3. Gujarati [ ] [ ] [ ]

4. [ ] [ ] [ ]

5. [ ] [ ] [ ]

[4] – EDUCATIONAL HISTORY : - ( High School onwards )

Diploma Principal Name & Place of Board / Class & Duration Duration
/ Degree Subject / School / College University % as a as a
Obtained Specialization Obtained Month Year

Page 4 of 7
(1) No. of years spent in hostel : ________________________________________________________

Did you ever fail in School College ? [ ] Yes [ ] No

If yes, give details : ___________________________________________________________________

___________________________________________________________________

(2) Short term and part time specialized external training programs attended : -

Description of course / Name & Place of the Institute Year Duration

programs

[5] – WORK EXPERIENCE : -

No. Employer’s Type Duration Position Held Salary & Reason

Name
& of Month & Year Designation Benefits for
City
Industry Start. Last Start. Last Start. Last leaving

(2) Are you bound by any secrecy / confidentiality agreement ? [ ] Yes [ ] No

(3) Do you know any one in this organization ? [ ] Yes [ ] No

If yes, give Name : ____________________________________________________________________

Division : ______________________________ Designation :

_________________________________

(4) Have you been employed earlier with the Company / Group Company ? [ ] Yes [ ] No

If yes,
Location : Corporate Office / Manufacturing / Field : _________________________________________

City : _______________

Page 5 of 7
 Division / Position Held Duration Last Salary Reason for
Company Starting Last From To Leaving

[6] - OTHER DETAILS : -

(1) Hobbies ( in order of interest ) : -

Self Spouse Child - 1 Child - 2

(2) Do you have any interest in sports / games ? [ ] Yes [ ] No

If yes, elaborate on your interests / achievements : -

Sports / Games Achievement

(3) Membership of any Social, Cultural, Political or Professional Organizations : -

Name of the Organization Duration of Membership Positions Held

From (Year) To (Year)

(4) Give Details of references ( other than relatives ), who have known you well personally : -

Name, Address & Phone No. Occupation Period for which he or Capacity in which he or
she knows you she knows you

Page 6 of 7
(5) Bank Account Details : -

Name of Bank Bank Account Number Name of Branch Payable Place for Cheque /
& City D. D

Note : { If you have Account in Standard Chartered / ICICI / UTI / HDFC Bank than mention Name, -
Account No., Branch & City of your Bank. If you don’t have Account in above mentioned Bank
than you have to mention Payable Place for Cheque / D. D }

I solemnly confirm that,

( i ) The information given in this form is true to the best of my knowledge.

( ii ) Any false information provided by me in this form will invite my immediate dismissal from the -
job.

Date : ____________________________ Signature : _____________________________________

Place : ____________________________ Name : ________________________________________

Space for additional information :

__________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

_________________________________

Signature

Page 7 of 7
 FORM –‘F’
PAYMENT OF GRATUITY ACT.
[ SEE SUB-RULE (1) of Rule 6 ]
NOMINATION
To,
…………………………………………………...
…………………………………………………...

[ I Give here name or description of the establishment with full address ]

1. Shri/Shrimati……………………………………………………………………………….
[Name in the here]

Whose particulars are given in the statement below. I 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 the 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 the person (s) mentioned is/are a 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 provision 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 Age of Proportion by which the
address of nominee(s) the employee nominee gratuity will be shared
(1) (2) (3) (4)
 STATEMENT
1. Name of the employee in full……………………………………………………………………..
2. Sex…………………………………………………………………………………………………..
3. Religion……………………………………………………………………………………………..
4. Whether unmarried/married/widow/widower……………………………………………………
5. Department Branch/Section where employed………………………………………………….
6. Post held with Ticket No. Serial No. if any………………………………………………………
7. Date of appointment……………………………………………………………………………….
8. Permanent address………………………………………………………………………………..
Village………………………………Thana……………………Sub Division……………………
Post Office………………………….District…………………..State…………………………….
Place-
Signature/Thumb Impression
Date……………. of the employee

Declaration by witnesses
Nomination signed/Thumb impressed before me
Name in full and full address of witnesses

signature of witnesses
Place:

Date………………………

Certificate by the employer

Certified that the particulars of the above nomination have been verified and recorded in this
establishment

Employer’s reference No, if any Signature of the employer/Officer authorized

Designation

Name address of the establishment

Date……………….. or rubber stamp there of

Acknowledgment by the employee

Received the duplicate of the nomination in Form ‘F’ Filled by me and duly certified by the
employer.

Date……………………

Note: Strike out words/paragraph not applicable Signature of the employee

 (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)

1. Name (IN BLOCK LETTERS) : _______________________________________________________________________________

Name Father’s / Husband’s Name Surname

2. Date of Birth : ___________________ 3. Account No. ___________________

4. *Sex : MALE/FEMALE: ______________________ 5. Marital Status ________________________________________

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

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

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)

Certified that I have no family as defined in para 2 (vii) of the Employees’s 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 Date of Birth Relationship with member

the nominee

Date ___________________

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 authorised officer of the

establishment

Place :
Name & address of the Factory /Establishment
Date :