FORM No 5A Date : 04-May-2018
EMPLOYEES' PROVIDENT FUND SCHEME 1952 (Please refer Para 36A)
EMPLOYEES' PENSION SCHEME 1995 (Please refer Para )
EMPLOYEES' DEPOSIT LINKED INSURANCE SCHEME1976 (Please refer Para 10)
(Ist RETURN OF OWNERSHIP AFTER ONLINE APPLICATION FOR CODE NUMBER)
[THIS FORM 5A HAS BEEN GENERATED BY ONLINE FILLING/ UPDATION OF FORM 5A THROUGH ECR LOGIN
OF EMPLOYER. APPLICATION NUMBER IS 2994308260.]
Code Number : ORBBS0015046000
1. Name of Establishment : M/S SARASWATI SISU MANDIR PRICHALANA SAMITI
2. Code Number of the Establishment under EPF Scheme 1952 : ORBBS0015046000
3. Postal address of the Establishment and its branches : MADHUBAN 1ST LANE, PURI-2, , PURI, PURI, ODISHA -
752002 [Please see Annexure I]
4. Industry or business in which engaged : SCHOOL
5. Date of commencement of business : 01/04/2005
6. Date of closure by previous management : N/A
7. Whether run by owner or lessee : Run by Owner
8. Particulars of owners :
S. Name Date of Status Father's Name Residential Address Position
No. Birth Date
9. In case on lease, particulars of lessee : N/A
S.No. Name Date of Birth Father's Name Residential Address Position
Date
10. If registered under Factories Act, particulars of Manager or occupier : N/A
11. Particulars of persons mentioned above who are incharge and responsible for conduct of business of the
S. Name Date of Status Father's Name Residential Address Position
No. Birth Date
Date: Signature of employer _____________________________
Name of Employer _____________________________
Designation of Employer _____________________________
Seal of Establishment Mobile number _____________________________
Application Number : 2994308260 Page 1 of 4
Code Number : ORBBS0015046000
Application Number : 2994308260 Page 2 of 4
Code Number : ORBBS0015046000
ANNEXURE - I
Details of Branches of the Establishment
ANNEXURE - II
List of Branches having Separate/ Sub Code Number
Application Number : 2994308260 Page 3 of 4
Code Number : ORBBS0015046000
SPECIMEN SIGNATURE CARD
To be submitted with all documents after the Code number is allotted through the online application.
FULL NAME OF THE AUTHORISED SIGNATORY __________________________________________________
Name of Establishment : M/S SARASWATI SISU MANDIR PRICHALANA SAMITI
Address of the Establishment : MADHUBAN 1ST LANE, PURI-2, , PURI, PURI, ODISHA - 752002
Code Number of the Establishment : ORBBS0015046000
STATUS OF THE SIGNATORY : # EMPLOYER / AUTHORISED SIGNATORY
# Strike whichever is not applicable
SPECIMEN SIGNATURE 1. _____________________________
2. _____________________________
3. _____________________________
SPECIAL INSTRUCTION, IF ANY _______________________________________________________
SPECIMEN SIGNATURE OF Mr/Ms _______________________________________________________ ATTESTED
Signature of employer _____________________________
Name of Employer _____________________________
Designation of Employer _____________________________
Seal of Establishment Mobile number _____________________________
[ ] Please tick if "Not Applicable" due to upload of digital signature
To be submitted separately for each Authorised Officer, if more than one.
Not to be submitted in this format if the employer after allotment of code number has uploaded digital signatures of the
Authorised signatories.
In such case the letter generated from the portal after uploading the digital signature(s) to be sent.
In case of upload of digital signature, when page (6) specimen signature card is not applicable, strike this, but keep as
enclosure to the form 5A.
Application Number : 2994308260 Page 4 of 4
Code Number : ORBBS0015046000
