Form - 9 (Revised)
THE EMPLOYEES' PROVIDENT FUNDS SCHEME, 1952 (PARA 36(1) and THE EMPLOYEES' PENSION SCHEME 1995 ( PARA 20 ) RETURN OF EMPLOYEES WHO ARE ENTITLED AND REQUIRED
TO BECOME MEMBERS OF THE EMPLOYEES' PROVIDENT FUND AND PENSION FUND.
NAME AND ADDRESS OF THE FACT/ESTT. CODE NO.
INDUSTRY IN WHICH THE FACT./ESTT. IS ENGAGED DATE OF COVERAGE
REGN. NO. OF THE FACTORY/ESTABLISHMENT DATE FROM WHICH
EMPLOYEES PENSION SCHEME IS APPLICABLE
If factory/Estt. Is covered under E.S.I. Act, indicate the code No. allotted under E.S. I. E.S.I. Code No. Name of the
If not, furnish the details of the designated Medical Officer of the factory/establishment designated Medical Officer
Specimen Signature of the Employer or authorised Official
Sr. No. Name Designation Specimen Signature
1
2
3
4
REMARKS, IF ANY:
NOTE: (1) This Form should be accompanied by declaration in Form-2 by every employee
(2) any change in the authorised official/designated medical officer should be intimated to the Commissioner
Signature of the employer or other authorised Officer]
Date and Stamp of Factory/Establishment
No. of employees enrolled as Members on the date of coverage………………..

CODE NO. Folio No. ……………………
FORM - 9 (Revised)
SL. No. Account Name of the employee ( Father's name (or husband's Date of birth Sex of Machine EDP NO. of Initials of S.S. Date and reason Remarks and initials on
Date of Total period
Number in block capital) name in the case of married eligibility of previous service Ledger Card opened of leaving service settlement D.C., S.S., A.O.,
woman) membership ( excluding periods of E.P.F., E.P.S., D.L.I.
breaks) as on the
date of joining the
Fund
1 2 3 4 5 6 7 8 9 10 11 12
Signature of the Employer