1.

a)Name of the NAGENDRAS BABU AMRUTHAM

member
1.b)Name of the ..........................................................
claimants
2.DOB 09-09-1990
3.Fathers Name KRISHNA MURTHY
4.Husbands Name
5.Name & Address of
establishment in which 6th Floor, BMTC Commercial Complex, 80 ft Road,
the employee was last Koramangala, Bangalore, Karnataka. PIN - 560 095
employed:-
6.Code No and Account Region/SRO Code K N B N G
No.
Estt. Code No BG/BNG/0035224

PF No. BG/BNG/0035224/000/0813724

7.Reason For Leaving

Service I got a great opportunity other company
8.DOL 08-09-2018
9.DOJ 01-10-2016
H No;106 Moulali Venkata Siva Sai Tower
10.Full Postal Address
,,TLG,001-500040
Sh/Smt./Km ..........................................................
S/o,W/o,D/o ..........................................................
Pin Code 500040

Emp Id: 1081395 For Teamlease Services

Mobile No: 8448194410 Ltd.
Permanent 8448194410
Telephone No.:
Authorized Signatory
E-Mail ID: amruthamnagendra@gmail.com

11.Are you Willing to accept scheme (a) (b) (a) (b)

Certificate in lieu of withdrawal benefits Yes No

12.Particulars of Family(Spouse & Children & Nominee)
Type Name Date of Relationship with Name of the guardian
: Minor Birth member of
(a)Family:
(a)Nominee:
13.In Case of death of member after attaining the age of 58 years without filing
the claim:-
(a)Date of death of the member:
(b)Name of the claimant(s) and relationship with the members:
14.MODE FOR REMITTANCE[PUT A TIC IN THE BOX AGAINST THE ONE
OPTED]
a)By postal money order at my cost to address given against item no.7
b)Account Payee cheque sent direct for credit to my SB A/c(scheduled
bank) under intimation to me
S.B.Account No 44411352450
Name of the Bank NEFT
Branch Jubilee hills
Full Address of the Branch 8 - 2 - 293 82 A 646 A, Ground Floor,, Hyderabad
IFSC Code SCBL0036090

15.Are you availing pension under EPS -95?

If so indicate:PPO No.........................by whom issued...............................

CERTIFIED THAT THE PARTICULARS ARE TRUE TO THE BEST OF MY

KNOWLEDGE
Date Signature or left hand thumb impression
of the member /claimants(s)

For Teamlease Services ltd

Authorized Signatory
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