UAN 100621838608

Mobile No. 9600258016

Employees' Provident Fund Scheme, 1952 Registration No.

Form -19 Registration Dt.

1. Name of the Member R THAMIZHVANAN

2. Father's Name or (Husband SUBRAMANI RAVI
name in case of married Woman)
NETWORK ELECTRONIC AND MECHANICAL
3. Name and Address of the REG.OFF.- SHOP NO.134,1ST FLOOR,'F'WI
Factory/Establishment DEVARSH BUILDING,LATIF PARK,
in which the member was working OPP.S.K.STONE,MIRA-BHAYANDAR ROAD,
MIRA ROAD(E) DIST TH

4. Account Number KD/MAL/93004/956

5. Date of Leaving Service 30/06/2016

6. Reason of Leaving Service

Personal Reason Cessation
6a.Permanent Account No. (PAN) AJSPT4858J
6b.Whether Submitting
Form No.15G/15H of Income Tax No
7. Full Postal Address 13A, 8TH STREET, BHAVANI NAGAR,
DHARAPADAWEDU, VELLORE,
TAMIL NADU - 632007

8. Mode of Remittance Bank, (Credit to my S.B. A/c.)

S.B.Account No. 6137559981

IFSC No.

Name of the Bank INDIAN BANK

(Branch) KATPADI
Address of the Branch R.D. COMPLEX, VELLORE MAIN ROAD
NR. CHITTOOR BUS STAND, KATPADI
STATE -TAMIL NADU,

Form No.5
A/c. Name of the Employee Father/Husband Name Date S Date Total period Remarks
No. of e of of previous service
Birth x Joining as on the date of
Joining the Fund
956 R THAMIZHVANAN SUBRAMANI RAVI 11/11/1991 M 01/12/2015

Form No.10
A/c. Name of the Employee Father/Husband Name Date Reason for Remarks
No. of Leaving
Leaving Service
Service
956 R THAMIZHVANAN SUBRAMANI RAVI 30/06/2016 Cessation

Certified that the particulars are true to the best of my knowledge

Date of Joining of Establishment 01/12/2015 Date of Birth 11/11/1991
The Applicant has signed/thumb impressed before me.

x For NETWORK ELECTRONIC AND MECHANICAL

Signature or Left/right hand thumb

impression of the Member
PATNER
Date :
Enclosers :
 Declaration of non-employment
I declare that I have not been employed in any factory/establishment to which the act
applies for a continuous period not less than 2 months immediately preceding the date
of my application for final withdrawal of my Provident Fund money.

x
Signature or Left/right hand thumb
Date : impression of the Member

ADVANCE STAMPED RECEIPT (To be furnished on in case of 8 (b) above)

Received a sum of Rs. _____________ Rupee______________________________________________
____________________________ from Regional Provident Fund Commissioner Office-in-Charge
of Sub Account-Office by Deposit in my Saving account towards the Settlement of P.F. A/c.

Signature or Left/right hand thumb

impression of the Member
For NETWORK ELECTRONIC AND MECHANICAL

Date : PATNER

(For the use of Commissioner's Office)

A/c.Settled in Part/Full Entered in F-21-A/24/219 and Withdrawal Register _____________
Clerk _________________________________ Section Supervisor
P.I.No. ____________________ M.O./Cheque _________________ Account No. ____________________
Section passed for payment of Rs._______________( in words _____________________________
______________________________________________________________________________M.O.Commission
(if any) AOC/APFC ______________________________________Net amount to be
paid by M.O. __________________________ Dt.________________________

Clerk Section Supervisor

(For use in Cash Section)

Paid by inclusion in Cheque No. ______________________________ Dt._____________________
Vide Cash Book (Bank) Account No.3 Debit item No._________________________________________

S.S. A.C. R.C.

Remarks