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FORM 11 ( Revised)

         THE EMPLOYEES’ PROVIDENT FUNDS SCHEME,1952 (Paragraph 34)

     THE EMPLOYEES’ FAMILY AND PENSION SCHEME, 1971 (Paragraph 19)

Declaration by a person taking up employment in an establishment in which
the Employees’ Provident Funds & Family Pension Fund Scheme enforce

I.......................................................................S/o/W/o/Daughterof..................................................
              ( NAME OF EMPLOYEE )
do hereby solemnly declare that :-

     (a)     I was employed in M/s.........................................................……................................................
                                          (NAME AND FULL ADDRESS OF THE ESTABLISHMENT)

        and left service on ....................prior to that, I was employed in.……………….................................
                                          ( DATE )                                              (NAME AND FULL ADDRESS
      ..........................................................................from.......................................to......................................
           OF THE ESTABLISHMENT)                                                                ( DATE )                    ( DATE )

      (b) I was member of ………................................………………………........Provident Fund and also/but
                                       ( Name of Trust or R. P. F. C.)
           not of the Pension Fund from.....................................to....................................... and my account
                                                ( DATE )                                     ( DATE )
           number (s) was/were......………………........
                                     ( PF No. )
      (c) I have/have not withdrawn the amount of my Provident Fund/Pension Fund.

      (d) I have/have not drawn any superannuation benefits in respect of my past service from any employer.

      (e) I have/have not never been a member of any Provident Fund and/or Pension Fund.

      (f) I am drawing/not drawing Pension under EPS 95.

      (g) I am a holder/not holder of scheme Certificate.

      (h) Scheme certificate surrendered/not surrendered.


Date.............................                                                                                      Signature or left hand thumb
                                                                                                                       impression of the employee.


(To be filled by the employer only when the person employed had not already been a member of the
Employees’ Provident Fund)

Shri/Smt………….....................................................................is appointed as.................................................
         (NAME OF EMPLOYEE)                                                                                  (DESIGNATION)
in M/s……………….............................................................................………with effect from..........................
      (NAME OF THE FACTORY/ESTABLISHMENT)                                                                    (DATE OF APPOINTMENT)

Account Number ………………………….


Date............................                                                             Signature of the Employer/Manager or Other
                                                                                                               Authorised Officer

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Pf form11

  • 1. FORM 11 ( Revised) THE EMPLOYEES’ PROVIDENT FUNDS SCHEME,1952 (Paragraph 34) THE EMPLOYEES’ FAMILY AND PENSION SCHEME, 1971 (Paragraph 19) Declaration by a person taking up employment in an establishment in which the Employees’ Provident Funds & Family Pension Fund Scheme enforce I.......................................................................S/o/W/o/Daughterof.................................................. ( NAME OF EMPLOYEE ) do hereby solemnly declare that :- (a) I was employed in M/s.........................................................……................................................ (NAME AND FULL ADDRESS OF THE ESTABLISHMENT) and left service on ....................prior to that, I was employed in.………………................................. ( DATE ) (NAME AND FULL ADDRESS ..........................................................................from.......................................to...................................... OF THE ESTABLISHMENT) ( DATE ) ( DATE ) (b) I was member of ………................................………………………........Provident Fund and also/but ( Name of Trust or R. P. F. C.) not of the Pension Fund from.....................................to....................................... and my account ( DATE ) ( DATE ) number (s) was/were......………………........ ( PF No. ) (c) I have/have not withdrawn the amount of my Provident Fund/Pension Fund. (d) I have/have not drawn any superannuation benefits in respect of my past service from any employer. (e) I have/have not never been a member of any Provident Fund and/or Pension Fund. (f) I am drawing/not drawing Pension under EPS 95. (g) I am a holder/not holder of scheme Certificate. (h) Scheme certificate surrendered/not surrendered. Date............................. Signature or left hand thumb impression of the employee. (To be filled by the employer only when the person employed had not already been a member of the Employees’ Provident Fund) Shri/Smt………….....................................................................is appointed as................................................. (NAME OF EMPLOYEE) (DESIGNATION) in M/s……………….............................................................................………with effect from.......................... (NAME OF THE FACTORY/ESTABLISHMENT) (DATE OF APPOINTMENT) Account Number …………………………. Date............................ Signature of the Employer/Manager or Other Authorised Officer