CANDIDATE PERSONAL FORM

(ALL FIELDS TO BE FILLED COMPLETELY)

Candidate Full Name: _______________________________________________________________

Fathers Name: _____________________________________________________________________

Mothers Name: ____________________________________________________________________

Date of Birth: ____________________ Place of Birth: __________________ ____ Caste:_______

Mobile Number: ___________________________ Blood Group: __________________________

Company Name:______________________________ Date of Joining___________________________

Email Address: _____________________________ Designation: -------------------------------------------------

Permanent Address:___________________________________________________________________

____________________________________________________________________________________

Current Address: ______________________________________________________________________

____________________________________________________________________________________

Land Line Number of Residence/Mobile/Emergency Contact Number:

__________________________________________________________

Pan Number : ___________________________ AADHAR NO: ___________________________

Years of Experience:_____________________________

Educational Qualification:________________________________________________________________

Family Member Details:

Name of Family Member Relationship DOB

Bank Account Number _________________________________________________

Bank: _______________ IFSC code: _________________

Deputed at: _________________

**Name & Contact of References (TWO) : 1.

2.
IMEI Number (*#06#):------------------------------------------
SIGNATURE OF CANDIDATE
  




   
   

 
 

 
 
 

 

    
   
 
     
     
  
   
  

     













 
 
 
 
 

 
 




  






 
 





     
     
   
  
   

 
 


 
  
   






  
  
 Genius Consultants Ltd.
PERSONAL DETAILS FOR ESIC E – PAHACHAN CARD

1. EMP ID:

2. ESIC NO:

3. ESIC DISPENCERY NAME :

4. NAME (FULL NAME):

5. FATHER/HUSBAND’S NAME:

6. CONTACT ADDRESS WITH PINCODE:

7. PERMANENT ADDRESS:

8. DATE OF BIRTH:

9. MOBILE NO:

10. ADHAR NO:

11. SEX (M/F):

12. MARITAL STATUS:

13. CLIENT NAME:
NOMINEE DETAILS
SL NAME DOB RELATION SHIP ADHAR CARD NO
NO
1

FAMILY DETAILS
SL NO NAME DOB RELATION ADHAR CARD NO
SHIP
1

2.

3.

EMPLOYEE SIGNATURE
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 (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 :