FORM 1





THE EMPLOYEES PROVIDENT FUNDS SCHEME, 1952 (Exemption under para. 27 of the Scheme)



I hereby apply for exemption from the operation of all or the following provisions of the scheme:

(a)………………..

(b) ………………..

(c)……………..

(d)………………..

(e)………………..

1. Name………………..

(in block letters)

2. Occupation………………..

3. Sex………………..

4. Religion………………..

5. Father’s Name………………..

6. Husband’s name (for married women only) ………………..

7. Permanent address………………..

8. Details of the provident fund, gratuity or old-age pension........................................

I declare that all the particulars stated above are true to the best of my knowledge and belief

Dated ……………….. 19

2[Signature or left hand thumb impression in case of both female and mate members of the fund]

Certified that the above declaration has been signed by……employed in** …………before me and that he/she is getting the benefits of provident fund, gratuity or old-age pension as above.

Dated……………….19

Signature of the Manager or other authorized officer of the Factory/ Establishment. Registered No. of the Factory Establishment].

**Here give the name and address of the factory or other establishment in which employed.

1. Subs. by G.S.R. 852, dated 6th May, 1963 (w.e.f. 18th May, 1963).

2. Subs. by G.S.R. 20, dated 26th December, 1984, published in the Gazette of India, Pt. II, Sec. 3(Q, dated 5th January, 1985 (w.e.f. 5th January, 1985).