Particulars of Employment
Registered number of 1[factory or other establishment]
Duration of Employment
Remarks
Initials of the employer's authorised clerk
From
To
The employer's and member's contribution should be shown separately for each
Employer's/member's total amount refunded
Week
Week
Week
Week
Week
Week
1
2
3
4
5
6
week
Week
Week
Week
Week
Week
Week
Week
Week
7
8
9
10
11
12
13
14
15
Week
Week
Week
Week
Week
Week
Week
Week
Week
16
17
18
19
20
21
22
23
24
Week
Week
Week
Week
Week
Week
Week
Week
Week
25
26
27
28
29
30
31
32
33
Week
Week
Week
Week
Week
Week
Week
Week
Week
34
35
36
37
38
39
40
41
42
Week
Week
Week
Week
Week
Week
Week
Week
Week
43
44
45
46
47
48
49
50
51
Week
52
Total contribution of the employer
Rs.
[n.p.]
Signature of the Employer's
Head Clerk or any Authorised Clerk
Total contribution by the member
Checked and found correct
Grand Total
Amount refunded
[*
* *]
Authorisedofficial of the Office of the Commissioner
FORM 5
The Employees' Provident Funds Scheme, 1952
[See paragraph 36(2)(A)]
The Employees' Pension Scheme, 1995
[See paragraph 20(4)]
The Employees' Deposit-Linked Insurance Scheme, 1976
[See paragraph 10(1-A)]
Return of Employees qualifying for membership of the Employees' Provident Fund, Employees'
Pension Fund and Employees' Deposit-Linked Insurance Fund for the first time during the month of ..............
(To be sent to the Commissioner with Form No. 2) (EPF and EPS)
Name and address of factory/ establishment .................................................... Code No. of the factory/ establishment........................................
Sl. No.
Account No.
Name of the employee (in block capitals)
Father's Name or Husband's name
(in case of married woman)
Date of Birth
Sex
Date of joining the fund
Total period of previous service as on the date of joining the fund (enclose Scheme Certificate if applicable)
Remarks
1
2
3
4
5
6
7
8
9
Date:
Stamp of the factory/ establishment
Signature of the Employer or other Authorised Officer of the Establishment