Date: 13 Dec 2023

Mr Santosh Ramesh Kadam

AtPost Shidod TqDistBeed

Pin­431122 431122

Employee No: 3196762

Dear Mr Santosh Ramesh Kadam

Fixed Term Contract

We are pleased to appoint you in our organization as subject to the following terms and conditions:

1. On joining, your Employee Code would be 3196762.

2. You are hereby appointed as Sales Officer for Two Year commencing from 13 Dec 2023 to 12 Dec 2025 or from
the actual date of Joining whichever is later, during which you will render services to our Client at their premises
subject to the terms and conditions of this engagement letter and in accordance to the instructions received by you
from us or any other authorized person and will be bound by our rules and regulations.

3. You hereby agree to be liable for the following terms and conditions:

i. Fully perform the services, in a professional manner, at the Client’s location until the completion of the term of
the work assignment.
ii. During the term of the work assignment, render services exclusively to the Client and such performance shall
not be inconsistent with any obligation you may have to other third parties.
iii. Not engage in any conduct which is detrimental to the interest of the Client or TeamLease.
iv. Not receive any payments of any nature directly or indirectly from the Client unless agreed to by TeamLease.
v. Neither directly nor indirectly offers you for employment with the Client or its affiliates during the period of the
work assignment without prior permission of TeamLease.
vi. Extend all cooperation to the Client’s employees, consultants, representatives, etc, and do all such things as
may be necessary and comply with all terms of the Appointment letter so as to effectively undertake the work.
vii. Report and be present at the designated location during the working hours mentioned herein and abide by the
rules and regulations as required by the Client.
viii. Comply with the safety, health and other rules and regulations of TeamLease and the TeamLease Client that
you have been made aware of.
ix. During the course of your contract, you can be transferred to a location within the territory of India as and
when required by TeamLease for executing the services provided herein.

4. The nature of your relationship with TeamLease will be that of a Contract of Service for a fixed period of Two
Years. By executing this letter of engagement neither do we offer you employment with TeamLease nor do you
become an employee of TeamLease. Upon expiry or termination of the Work Assignment, your employment with
TeamLease shall stand terminated forthwith.

5. Except for expiry of a Work Assignment due to completion/expiry of the same or in respect of a Work Assignment of
one week or a lesser period of time, either party may terminate this Work Assignment Letter by issuing 30 days
notice in writing or payment thereof.

6. You will be entitled to 30 days General Leave in a financial year at a time to be determined by the Company.

7. If at any time, you are found overstaying sanctioned leave or absence from work without permission for a period
exceeding five consecutive days or habitual absence or similar misconduct considered by TeamLease or its Client
to be gross indiscipline, you will be considered to have abandoned your services with TeamLease. This will be
treated as voluntary termination of services from your end and incentives withheld. TeamLease will not be liable to
pay one month’s salary in lieu of notice thereof in such cases.

8. This contract may be terminated by either party giving to the other not less than one month's prior written notice.
TeamLease shall be entitled, whether such notice of termination is given by you or TeamLease, to require you to
proceed on leave at the time of receiving or giving such notice of termination or at any time thereafter. TeamLease
shall also be entitled to terminate your services forthwith by paying one month's salary in lieu of notice.
**This is a system generated document. Any unauthorized use, disclosure, dissemination, or copying of this document is strictly prohibited and may beeSigned
unlawful.**
using Aadhaar
(Leegality.com - bE0RKT6)
9. Termination of this letter of engagement shall not affect the obligations of the parties that Santosh
Doc ID: TL/31C3BEE81CA have been
Rameshincurred
Kadam prior
to such termination and TeamLease shall promptly settle all your dues after making the applicable
Date: Fri Decdeductions.
15 17:07:31 IST
TeamLease Services Limited., CIN No. L74140KA2000PLC118395 2023
Ascent Building , # 77,Koramangala Industrial Layout, Jyothi Nivas College Road, Koramangala , Bangalore-560095.
10. You agree to defend, indemnify and hold TeamLease or the Client harmless from any and all claims, damages,
Ph : (91-80) 33002345, Fax : (91-80) 33243001 www.teamlease.com
liability, attorneys fees and expenses on account of your failure to satisfy any of your obligations under this work
assignment letter or for misconduct or for violation of any law or creation of any legal liability by you.
 6. You will be entitled to 30 days General Leave in a financial year at a time to be determined by the Company.

7. If at any time, you are found overstaying sanctioned leave or absence from work without permission for a period
exceeding five consecutive days or habitual absence or similar misconduct considered by TeamLease or its Client
to be gross indiscipline, you will be considered to have abandoned your services with TeamLease. This will be
treated as voluntary termination of services from your end and incentives withheld. TeamLease will not be liable to
pay one month’s salary in lieu of notice thereof in such cases.

8. This contract may be terminated by either party giving to the other not less than one month's prior written notice.
TeamLease shall be entitled, whether such notice of termination is given by you or TeamLease, to require you to
proceed on leave at the time of receiving or giving such notice of termination or at any time thereafter. TeamLease
shall also be entitled to terminate your services forthwith by paying one month's salary in lieu of notice.

9. Termination of this letter of engagement shall not affect the obligations of the parties that have been incurred prior
to such termination and TeamLease shall promptly settle all your dues after making the applicable deductions.

10. You agree to defend, indemnify and hold TeamLease or the Client harmless from any and all claims, damages,
liability, attorneys fees and expenses on account of your failure to satisfy any of your obligations under this work
assignment letter or for misconduct or for violation of any law or creation of any legal liability by you.

11. Any dispute between you and TeamLease shall be referred to a sole arbitrator appointed by TeamLease. The
arbitration shall be conducted in English language, in accordance with the Arbitration and Conciliation Act 1996, at
Bangalore, Karnataka, India. This Engagement Letter shall be governed by the laws of India.

12. Details of your salary breakup will be as per the Annexure attached herein. You hereby authorize TeamLease to
make all salary payments required to be made to you by TeamLease including all reimbursements either by way of
Cheque or by directly crediting the amounts to your bank account.

13. You will be entitled to an employer’s contribution of Provident fund to the extent of 12% of your basic salary and
ESI contribution, if applicable. You will also be covered under Medical and Accident Insurance and will be entitled
to all other statutory benefits whichever is applicable during the contract period. It is hereby clarified that if you fail
to submit complete ESIC, PF, Gratuity nomination forms together with any other document as required under the
applicable labour legislations, TeamLease shall not incur any liability with regards to any Claims under the said
applicable labour legislations.

14. In addition to the terms contained herein, your relationship with TeamLease may be subject to such other additional
terms and conditions as may be communicated to you from time to time in writing by TeamLease and you hereby
agree to have read and clearly understood the terms of employment provided in the Service Rules, which is
attached herein.

15. The nature of your relationship with TeamLease will be that of contract of service from 13 Dec 2023 to 12 Dec
2025 . Upon expiry or termination of the work Assignment, your employment with TeamLease shall stand
terminated forthwith.

16. Upon resignation or early termination of your fixed term contract, an amount of Rs. 500/­ (Rupees Five Hundred
Only) shall be deducted from your full and final settlement towards the Alumni & Learning Fee. This Fee is towards
Lifetime Access to the TeamLease Alumni App, where you will continue to have access to the TeamLease Learning
portal to be able to access free courses. You will also get various job recommendations from our TL Connect Job
portal basis your career interests. Additionally on the TeamLease App, you will also be able to view & download
your Payslips, Appointment letter, relieving letter, PF statement, Income Tax statement etc.

17. .“You shall not, either during or after termination of your employment with client give out to any third part by word of
mouth or otherwise, the Proprietary and/or Confidential Information of the Company, that shall include but not
limited to all information, software (whether in object or source code), statistics, data, data base, knowledge, trade
secrets, inventions, products detail, know­how, formula, processes, designs, drawings, charts, maps, concepts,
ideas, systems, project plans, business plans, client details, security information, any other creations of whatsoever
nature, kind or description, organizational matters pertaining to company or our client. Further, you shall not at any
time, whether during or after the period of employment, use such Proprietary or Confidential information or any part
eSigned using Aadhaar
thereof, for your own benefit or for the benefit of any person, firm, company or other
(Leegality.com legal entity other that our
- bE0RKT6)
client. This Non­Disclosure obligations enumerated above shall be binding SantoshonRamesh
you atKadam
all times, irrespective of
whether you continue to be employed by the company or not. Date: Fri Dec 15 17:07:31 IST
2023

18. .This appointment letter shall be co­terminus with the agreement we have with our client.

19. Upon joining, an amount of Rs. 399/­ shall be deducted from your first month pay towards Assessment and
Verification Fee. This will include Soft Skills Assessment along with a detailed Assessment report conducted at the
time of joining, Suggested Skill building Certification courses along with access to Learning content on our
Learning platform.

We at TeamLease would like to create an environment and culture committed to co­operation, quality and
responsiveness that permeates every activity. As a new entrant we would like you to add value to this process.Please
**This is return
a system generated
the copy document.
of theAny unauthorizedLetter
enclosed use, disclosure, dissemination,
duly signed or copying
in token of ofyou
this document
havingisread
strictly ,prohibited
agreedand may beunderstood
, fully unlawful.** and accepted
Doc ID: the terms and conditions of appointment. In case we do not receive your acknowledgement copy within a period of 15
TL/31C3BEE81CA
days from the date of joining, your assignment at TeamLease with the acceptance of your first salary from TeamLease
TeamLease Services Limited., CIN No. L74140KA2000PLC118395
will be conclusive proof of your acceptance in accordance of terms and conditions.
Ascent Building , # 77,Koramangala Industrial Layout, Jyothi Nivas College Road, Koramangala , Bangalore-560095.
Ph : (91-80) 33002345, Fax : (91-80) 33243001 www.teamlease.com
ENDORSEMENT
 thereof, for your own benefit or for the benefit of any person, firm, company or other legal entity other that our
client. This Non­Disclosure obligations enumerated above shall be binding on you at all times, irrespective of
whether you continue to be employed by the company or not.

18. .This appointment letter shall be co­terminus with the agreement we have with our client.

19. Upon joining, an amount of Rs. 399/­ shall be deducted from your first month pay towards Assessment and
Verification Fee. This will include Soft Skills Assessment along with a detailed Assessment report conducted at the
time of joining, Suggested Skill building Certification courses along with access to Learning content on our
Learning platform.

We at TeamLease would like to create an environment and culture committed to co­operation, quality and
responsiveness that permeates every activity. As a new entrant we would like you to add value to this process.Please
return the copy of the enclosed Letter duly signed in token of you having read , agreed , fully understood and accepted
the terms and conditions of appointment. In case we do not receive your acknowledgement copy within a period of 15
days from the date of joining, your assignment at TeamLease with the acceptance of your first salary from TeamLease
will be conclusive proof of your acceptance in accordance of terms and conditions.

ENDORSEMENT

I hereby confirm acceptance of the above assignment, on the terms and conditions stipulated therein.

For TEAMLEASE SERVICES LIMITED Accepted and Agreed

_________________________ ________________________
Signature and date:
(Authorized Signatory) Name: SANTOSH RAMESH KADAM

Salary Annexure

Employee No: 3196762

Particulars Amount
Basic 5500
House Rent Allowance 2200
Employer PF Contribution 1371
ESIC ­ Employer 443
Works Allowance 5929
TotalAmount 15443
Amount In Words(Rs) Fifteen Thousand Four Hundred Forty Three Rupees

Net Pay Annexure

EARNINGS Amount
Basic 5500
House Rent Allowance 2200
Works Allowance 5929
Gross Earnings 13629

DEDUCTIONS * Amount
Employee ESI 103
Employee PF 1371
Total Deduction 1474

Net Salary 12155

* Income­tax deductions, if applicable, will be as per the Income­Tax Act, 1961

eSigned using Aadhaar
** Annual
(Leegality.com components
- bE0RKT6) (like LTA, Medical Reimbursement) would be payable on claims and will be considered for
Santosh Ramesh Kadam
exemption under Income Tax subject to receipt of valid bills for the Financial Year if applicable
Date: Fri Dec 15 17:07:31 IST
2023
Note : This statement is only for the purpose of information and is illustrative in nature

**This is a system generated document. Any unauthorized use, disclosure, dissemination, or copying of this document is strictly prohibited and may be unlawful.**
Dated: 13 Dec 2023
Doc ID: TL/31C3BEE81CA
TeamLease Services Limited., CIN No. L74140KA2000PLC118395
Ascent Building , # 77,Koramangala Industrial Layout, Jyothi Nivas College Road, Koramangala , Bangalore-560095.
The Branch Manager Ph : (91-80) 33002345, Fax : (91-80) 33243001 www.teamlease.com
 For TEAMLEASE SERVICES LIMITED Accepted and Agreed

_________________________ ________________________
Signature and date:
(Authorized Signatory) Name: SANTOSH RAMESH KADAM

Salary Annexure

Employee No: 3196762

Particulars Amount
Basic 5500
House Rent Allowance 2200
Employer PF Contribution 1371
ESIC ­ Employer 443
Works Allowance 5929
TotalAmount 15443
Amount In Words(Rs) Fifteen Thousand Four Hundred Forty Three Rupees

Net Pay Annexure

EARNINGS Amount
Basic 5500
House Rent Allowance 2200
Works Allowance 5929
Gross Earnings 13629

DEDUCTIONS * Amount
Employee ESI 103
Employee PF 1371
Total Deduction 1474

Net Salary 12155

* Income­tax deductions, if applicable, will be as per the Income­Tax Act, 1961

** Annual components (like LTA, Medical Reimbursement) would be payable on claims and will be considered for
exemption under Income Tax subject to receipt of valid bills for the Financial Year if applicable

Note : This statement is only for the purpose of information and is illustrative in nature

Dated: 13 Dec 2023

The Branch Manager

HDFC BANK LTD

Subject: Introduction Letter for Salary Account

eSigned using Aadhaar
(Leegality.com - bE0RKT6)
Santosh Ramesh Kadam

Dear Sir, Date: Fri Dec 15 17:07:31 IST

2023

We hereby confirm that below mentioned employee are bonafide employees of TeamLease Services Ltd,
Bangalore and we would like to confirm the below details are as per our records.

SL No. Emp. Code Emp. Name Location

**This is a system generated document. Any unauthorized use, disclosure, dissemination, or copying of this document is strictly prohibited and may be unlawful.**
1 3196762 Santosh Ramesh Kadam Beed
Doc ID: TL/31C3BEE81CA
TeamLease Services Limited., CIN No. L74140KA2000PLC118395
Ascent Building , # 77,Koramangala Industrial Layout, Jyothi Nivas College Road, Koramangala , Bangalore-560095.
This letter is given to thePhabove employee
: (91-80) 33002345, towards zero33243001
Fax : (91-80) balance salary account activation purpose.
www.teamlease.com
 * Income­tax deductions, if applicable, will be as per the Income­Tax Act, 1961
** Annual components (like LTA, Medical Reimbursement) would be payable on claims and will be considered for
exemption under Income Tax subject to receipt of valid bills for the Financial Year if applicable

Note : This statement is only for the purpose of information and is illustrative in nature

Dated: 13 Dec 2023

The Branch Manager

HDFC BANK LTD

Subject: Introduction Letter for Salary Account

Dear Sir,

We hereby confirm that below mentioned employee are bonafide employees of TeamLease Services Ltd,
Bangalore and we would like to confirm the below details are as per our records.

SL No. Emp. Code Emp. Name Location

1 3196762 Santosh Ramesh Kadam Beed

This letter is given to the above employee towards zero balance salary account activation purpose.

This letter is given subsequent out banking arrangements with HDFC Bank, Bangalore.

Company Name: TeamLease Services Ltd

Company Code: T0559

Request you to please do the needful .If any clarifications please write to [email protected]

Yours sincerely,

For TeamLease Services Ltd

Authorised Signatory,
eSigned using Aadhaar
(Leegality.com - bE0RKT6)
SantoshName: Hari Krishna
Ramesh Kadam PL
Date: Fri Dec 15 17:07:31 IST
2023 Designation: Senior General Manager – Staffing Operations

Mandatory Training Programme ­ Prevention of Sexual Harassment at Work Place ­ The Sexual Harassment
of Women at Workplace (Prevention, Prohibition and Redressal) Act 2013 (Act)

**This is In accordance
a system with the
generated document. Anyprovisions of disclosure,
unauthorized use, the above Act andor the
dissemination, Policy
copying of this of the Company
document to create
is strictly prohibited and mayawareness
be unlawful.** on prevention of
Doc ID: sexual harassment at workplace, we urge you to undergo an online training programme, on the subject matter.
TL/31C3BEE81CA

TeamLease
Please note that undergoing online ServicesisLimited.,
training mandatoryCIN No.
forL74140KA2000PLC118395
this engagement.
Ascent Building , # 77,Koramangala Industrial Layout, Jyothi Nivas College Road, Koramangala , Bangalore-560095.
Ph : (91-80)
The link to undergo the programme and33002345,
completeFax
the: (91-80) 33243001
evaluation www.teamlease.com
is given below.
 Authorised Signatory,

Name: Hari Krishna P L

Designation: Senior General Manager – Staffing Operations

Mandatory Training Programme ­ Prevention of Sexual Harassment at Work Place ­ The Sexual Harassment
of Women at Workplace (Prevention, Prohibition and Redressal) Act 2013 (Act)

In accordance with the provisions of the above Act and the Policy of the Company to create awareness on prevention of
sexual harassment at workplace, we urge you to undergo an online training programme, on the subject matter.

Please note that undergoing online training is mandatory for this engagement.

The link to undergo the programme and complete the evaluation is given below.

Link : https:tlconnect.teamlease.com/Learning

The training programme shall be conducted on a regular basis every year. Please complete the training programme
within 15 days of receipt of this letter, after which it shall be treated as a deemed confirmation that you have understood
your responsibilities in ensuring a safe workplace.

eSigned using Aadhaar

(Leegality.com - bE0RKT6)
Santosh Ramesh Kadam

**This is a system generated document. Any unauthorized use, disclosure, dissemination, or copying of this document is strictly
Date: prohibited
Fri and may 15
Dec be unlawful.**
17:07:31 IST
2023
Doc ID: TL/31C3BEE81CA
TeamLease Services Limited., CIN No. L74140KA2000PLC118395
Ascent Building , # 77,Koramangala Industrial Layout, Jyothi Nivas College Road, Koramangala , Bangalore-560095.
Ph : (91-80) 33002345, Fax : (91-80) 33243001 www.teamlease.com
 Emp Code # 3196762

SPECIMEN FORM 2 (REVISED)

GROUP No. :
NOMINATION & DECLARATION FORM
Office :
FOR UNEXEMPTED / EXEMPTED ESTABLISHMENTS

Declaration and Nomination Form under the Employees Provident Funds

and Employees Pension Scheme

(Paragraph 33 & 61 (1) of the Employees Provident Funds Scheme, 1952 and
Para 18 of the Employees Pension Scheme, 1995)

1. NAME (in block letters ) : Santosh Ramesh Kadam

2. FATHER'S / HUSBAND'S NAME : Ramesh Yadavrao Kadam
3. DATE OF BIRTH : 07-May-1995
4. SEX : Male
5. MARITAL STATUS : Married
6. ACCOUNT NO : KN/BN:KN/35224
7. ADDRESS : At.Post. Shidod,
Tq.Dist.Beed,
Beed - 431122

PART - A (EPF)

I hereby nominate the persons(s) / cancel the nomination made by me previously and nominate the person(s), mentioned below to receive the amount
standing to my credit in the Employees Provident Fund in the event my death.

Total amount or share of

Name & Address of the Nominee(s) Nominee's accumulation in PF to be If the nominee is minor, name & relationship &
relationship with the Date of Birth add. of the guardian who may receive the
paid in each nominee
member amount during minority of nominee

(1) (2) (3) (4) (5)

Priyanka Santosh Kadam, At.Post. Shidod, Spouse 27 - Mar - 1996 100

eSignedNousing Aadhaar
Tq.Dist.Beed, Beed- 431122 (Leegality.com - bE0RKT6)
Santosh Ramesh Kadam
Date: Fri Dec 15 17:07:31 IST
2023

1. * Certificate that I have no family as defined in para 2 (g) of the Employees Provident Funds Scheme, 1952 and should I acquire a family thereafter
the above nomination should be deemed as cancelled.
2. * Certified that my father / mother is / are dependent upon me.
(*) Strike out whichever is not applicable.

X ________________________________________________________
SIGNATURE OR THUMB IMPRESSION THE SUBSCRIBER
 Emp Code # 3196762

PART - B (EPS)
Para 18
I hereby furnish below particulars of the members of my family who would be eligible to receive widow / children Pension in the event of my death.

Sr. No. Name & Address of the family member/s Date of Birth Relationship with Member

(1) (2) (3) (4)

1 Priyanka Santosh Kadam, At.Post. Shidod, Tq.Dist.Beed, Beed- 431122 27 - Mar - 1996 Spouse

**Certified that I have no family, as defined in para 2 (vii) of the Employees Pension Scheme, 1995 and should I acquire a family here after I shall
furnish particulars thereon in the above form.

I hereby nominate the following person for receiving the monthly family pension (admissible under para 16 (2) (i) and (ii) in the event of my death
without leaving and eligible family member/s for receiving pension.

Name of the Nominee Address Date of Birth Relationship with

Member

(1) (2) (3) (4)

Priyanka Santosh Kadam At.Post. Shidod, Tq.Dist.Beed, Beed- 431122 27 - Mar - 1996 Spouse

Date : 15-Dec-2023 X
_________________________ _________________________________________________________________
(*) Strike out whichever is not applicable SIGNATURE OR THUMB IMPRESSION THE SUBSCRIBER
_______________________________________________________________________________________________________________________________________________________

CERTIFICATE BY EMPLOYER
CERTIFICATE that the above declaration and nomination has been signed / thumb impressed before me.

by Shri / Smt. / Miss. ________________________________________________________________________________________________ employed in my /

our establishment after he / she has read the entire / the entries have been read over to him / her by me and confirmed by him her
For TeamLease Services Limited

Place : __________________ Authorized Signatory

Date : ________________________________________________________________________________
Signature of the Employer's OR other Authorised Officer's the Establishments
Signature with Designation
TeamLease Services Ltd
6th Floor, BMTC Commercial Complex,
eSigned using Aadhaar 80 Feet Road, Koramangala,
(Leegality.com - bE0RKT6)
Santosh Ramesh Kadam Bangalore – 560095.
(Name and address of the factory /estt. Or rubber stamp thereof)
Date: Fri Dec 15 17:07:31 IST
2023
 Emp Code # 3196762

UNDER THE PAYMENT OF GRATUITY ACT, 1992.

&
THE PAYMENT OF GRATUITY (MAHARASHTRA) RULE, 1972

FORM 'F'
(See Sub-Rule (i) of rule (6)

Nomination

To
M/s TeamLease Services Limited
6th Floor, BMTC Commercial Complex,
80 Feet Road,
Koramangala,
Bangalore – 560095. eSigned using Aadhaar
(Leegality.com - bE0RKT6)
Santosh Ramesh Kadam
Date: Fri Dec 15 17:07:31 IST
1. Shri / Shrimati / Kumari SANTOSH RAMESH KADAM whose particulars are given 2023 in the statement below hereby nominate the person(s)
mentioned below to receive the gratuity payable after my death as also the gratuity standing to my credit in the event of my death before that
amount has become payable, or having become payable has not been paid and direct that the said amount of gratuity shall be paid in
proportion indicated against the name(s) of the nominee(s).

2. I hereby certify that the person(s) mentioned is / are member(s) of my family within the meaning of clause (h) of section 2 of the Payment of
Gratuity Act, 1972.

3. I hereby declare that I have no family within the meaning of clause (h) of section (2) of the said Act.

4. (a) My father / mother / parents is / are not dependent on me.

(b) My husband's father / mother / parents is / are not dependent on my husband.

5. I have excluded my husband from my family by a notice dated the to the controlling authority in terms of the provison to clause(s) of section
2 of the said Act.

6. Nomination made herein invalidates my previous nomination.

NOMINEE (S)
Sr. No. Name If Full address of the nominee(s) - (1) Relationship with the Age of the Nominee Proportion by which the
Employee (2) (3) gratuity will be shared (4)

1 Priyanka Santosh Kadam,At.Post. Shidod, Tq.Dist.Beed, Beed-

431122 Spouse 27 - Mar - 1996 100

6
eSigned using Aadhaar
(Leegality.com - bE0RKT6)
Santosh Ramesh Kadam
Date: Fri Dec 15 17:07:31 IST
2023
 Emp Code # 3196762

Statement
1 Religion Hinduism

2 Sex. Male

3 Name of employee in full. Santosh Ramesh Kadam

4 Whether married/unmarried/widow Married

5 Department/Branch/Section where Beed

employed

6 Post held with Ticket or Serial Number if any. Sales Officer

7 Date of appointment. 15-Dec-2023

8 Permanent address. At.Post. Shidod, Tq.Dist.Beed, Beed - 431122

Village Thana Sub-division

Post Office District State

Place : Beed X ____________________________________________

Date : 15-Dec-2023 Signature/Thumb impression of the employee

Declaration by witnesses
I declare that the Nomination has been signed/thumb impressed before me.

Name in full Signature of Witnesses. Address of witnesses

1. ___________________________________________ 1. ______________________________________

2. ___________________________________________ 2. ______________________________________

Place : Beed Place : Beed

Certificate by the employer

Certified that the particulars of the above nomination have been verified and recorded in this establishment.

Employer's References No., If any. For TeamLease Services Limited

Designation

Authorized Signatory

Name and address of the ___________________________________________

of rubber stamp thereof Signature/Thumb impression of the Authorized Signatory

Acknowledgement by the employee

Received the duplicate copy of nomination in Form 'F' filed by me and duly certified by the employer.

Date _______________________ ___________________________

Signature of the employee

Note : Strike out the words and paragraphs not applicable. eSigned using Aadhaar
(Leegality.com - bE0RKT6)
Santosh Ramesh Kadam
Date: Fri Dec 15 17:07:31 IST
2023
 www.epfindia.com
Composite Declaration Form Form -11
(To be retained by the Employer for future reference) 3196762
EMPLOYEES' PROVIDENT FUND ORGANIZATION
Employees' Provident Funds Scheme, 1952 (Paragraph 34 & 57) &
Employees' Pension Scheme, 1995 (Paragraph 24)
(Declaration by a person taking up employment in an establishment on which EPFS 1952 and/or EPS 1995 is applicable)

1 Name of the Member

Santosh Ramesh Kadam
eSigned using Aadhaar
Fathers' Name ✔ (Leegality.com - bE0RKT6)
2
Spouse's Name Ramesh Yadavrao Kadam Santosh Ramesh Kadam
Date: Fri Dec 15 17:07:31 IST
2023

3 Date of Birth (DD/MM/YYYY)

07/05/1995
4 Gender: (Male/Female/Transgender) Male
5 Marital Status(Married/Unmarried/Widow/Widower/Divorcee) Married
6
(a) Email Id: [email protected]
(b) Mobile No.: 9545754552
Present employment details:
7 15/12/2023
Date of joining in the current establishment (DD/MM/YYYY)

KYC Details (attach self attested copies of following KYCs)

a) Bank Account No.: 40339222477
8 b IFS Code of the branch: SBIN0018211
c) AADHAAR Number: 787150237135
d) Permanent Account No. (PAN), if available GTSPK5762G
Whether earlier a member of Employees' Provident
9 Yes No ✔
Fund Scheme, 1952 ?

Whether earlier a member of Employees' Pension

10 Yes No ✔
Scheme, 1995 ?

Previous employment details [if Yes to 9 &/or 10 above] - Un-exempted

Scheme
PPO Non Contri-
Establishment Universal Account PF Account Date of joining Date of exit Certificate
Number (if butory Period
Name & Address Number Number (DD/MM/YYYY) (DD/MM/YYYY) No. (if
issued) (NCP) Days
issued)

11

Previous employment details [if Yes to 9 &/or 10 above] - For Exempted Trusts
Scheme Non Contri-
Establishment Name & Universal Account Member EPS Date of joining Date of exit Certificate butory
Address Number A/C Number (DD/MM/YYYY) (DD/MM/YYYY) No. (if Period (NCP)
issued) Days
12

a) International Worker: Yes No ✔

b) If yes, state country of origin

13 (India/Name of other country)

c) Passport No.

d)Validity of passport [(DD/MM/YYYY) to (DD/MMYYYY @ From To

 UNDERTAKING
1) Certified that the particulars are true to the best of my knowledge.
2) I authorize EPFO to use my Aadhaar for verification/authentication/eKYC purpose for service delivery.
3) Kindly transfer the funds and service details, if applicable, from the previous PF account as declared above to the present PF Account as
I am an Aadhaar verified employee in my previous PF Account *

4) In case of changes in above details, the same will be intimated to employer at the earliest.

Date: 15-Dec-2023
Place: Beed Signature of the Member
DECLARATION BY PRESENT EMPLOYER

A. The member Mr./Ms./Mrs. has joined on

and has been allotted PF Number and UAN

B. In case the person was earlier not a member of EPF Scheme, 1952 and EPS, 1995:

● Please Tick the Appropriate Option:

The KYC details of the above member in the UAN database

Have not been uploaded

Have been uploaded but not approved

Have been uploaded and approved with DSC.e-sign

C. In case the person was earlier a member of EPF Scheme, 1952 and EPS, 1995:

● Please Tick the Appropriate Option:

The KYC details of the above member in the UAN database have been approved with E-sign/Digital Signature Certificate and
transfer request has been generated on portal.

The previous Account of the member is not Aadhaar verified and hence physical transfer form shall be initiated.

eSigned using Aadhaar

(Leegality.com - bE0RKT6)
Santosh Ramesh Kadam
Date: Fri Dec 15 17:07:31 IST
2023

Date: Signature of Employer with Seal of Establishment

* Auto transfer of previous PF account would be possible in respect of Addhaar verified employees only. Other employees to fill physical claim (Form-13) for
transfer of account from pervious establishment.

eSigned using Aadhaar

(Leegality.com - bE0RKT6)
Santosh Ramesh Kadam
Date: Fri Dec 15 17:07:31 IST
2023
 ?kks"k.kk i=k DECLARATION FORM Offer Ref # 3196762 QkeZ&1@Form-1
?kks"k.kk i=k deZpkjh }kjk Hkjk tk,xkA QkeZ ds LkkFk iksLVdkMZ vkdkj ds nks QksVksxzkQ Hkh yxk, tkus pkfg,A QkeZ Hkjus ls igys
ihB i`"B ij nh xbZ fgnk;rksa dks Hkyh&Hkkafr i<+ ysuk pkfg,A ;g QkeZ fu%'kqYd gSA
To be filled by employee after reading instruction overleaf. Two Postcard Size phtographs to be attached with the
form. This form is free of cost.
¼d½ chekÑr O;fDr ds fooj.k ¼[k½ fu;kstd ds fooj.k
(A) INSURED PERSON'S PARTICULARS (B) EMPLOYER'S PARTICULARS

1- chek la[;k@Insurance No. 9- fu;kstd dh dwV la[;k

Employer's Code No.
2- uke ¼Li"V v{kjks esa½
Name in block letters Santosh Ramesh Kadam 10- fu;qfDr dh rkjh[k fnu eghuk o"kZ
Date of Appointment Day Month Year
3- firk@ifr dk uke 15 12 2023
Father's/Husband's Name Ramesh Yadavrao Kadam
11- fu;kstd dk uke vkSj irk@Name & Address of the Employer
4- tUe dh frfFk fnu eghuk o"kZ 5- oSokfgd fookfgr@ __________________________________________________
Date of Birth Day Month Year izkfLFkfr vfookfgr __________________________________________________
Marital ✔fo/kok __________________________________________________
Status M/U/W 12- ;fn igys fu;kstu esa jgs gSa rks Ñi;k fuEufyf[kr C;kSjs nhft,
✔
In case of any previous employment please fill up the details as under.
07 05 95 6-fyax@Sex iq-e-/M.F.
7- orZeku irk@Present Address 8- LFkk;h irk@Permanent Address ¼d½ fiNyh chek la[;k
______________________
At.Post. Shidod ______________________
At.Post. Shidod (a) Previous Ins. No.
______________________
Tq.Dist.Beed ______________________
Tq.Dist.Beed ¼[k½ fu;kstd dwV la[;k
______________________
Beed,Maharashtra ______________________
Beed,Maharashtra (b) Employer's Code No.
fiu dksM 3 1 1 2 2
fiu dksM 3 1 1 2 2
4 4
Pin Code Pin Code ¼x½ fu;kstd dk uke o irk
VsyhQksu uEcj@bZ&esy irk@ [email protected] VsyhQksu uEcj@bZ&esy irk@ 9545754552 (c) Name & Address of the Employer

'kk[kk dk;kZy; vkS"k/kky;

Branch Office Dispensary
VsyhQksu uEcj@bZ&esy irk@e-mail address
¼d½ e`R;q dh fLFkfr esa udn fgrykHk ds Hkqxrku ds fy, d-jk-ch- vf/kfu;e] 1948 dh /kkjk 71@d-jk-ch- ¼dsUnzh;½ fu;e] 1950 ds fu;e 56¼2½ ds varxZr ukfer ds C;kSjsA
(c) Details of Nominee u/s 71 of ESI Act 1948/Rule-56(2) of ESI (Central) Rules, 1950 for payment of cash benefit in the event of death.

uke@Name ukrsnkjh@Relationship irk@Address

Priyanka Santosh Kadam Spouse At.Post. Shidod,Tq.Dist.Beed,Beed,431122
eSa ,rn~}kjk ?kks"k.kk djrk@djrh gwa fd esjs }kjk izLrqr fd, x, fooj.k esjh tkudkjh vkSj fo'okl ds vuqlkj lgh gSA eSa vius ifjokj ds lnL;ksa esa gq, ifjorZu dh lwpuk
15 fnu ds Hkhrj izLrqr djus dk opu Hkh nsrk gwa@nsrh gwaA
I hereby decalare that the particulars given by me are correct to the best of my knowledge and belief. I undertake to intimate the corporation any
changes in the membership of my family within 15 days of such change.

fu;kstd ds izfrgLrk{kj chekÑr O;fDr ds gLrk{kj@vaxwBk fu'kku

Counter signature by the employer Signature /T.I.of IP.

lhy lfgr gLrk{kj

X
Signature with seal
¼?k½ chekÑr O;fDr ds ifjtuksa dk fooj.k
(D) Family Particulars of Insured person
Ø-la- uke QkeZ Hkjus dh rkjh[k deZpkjh ds lkFk ukrsnkjh D;k muds lkFk jg ;fn ugha rks vkokl
SI. No. Name dks vk;q@tUe&rkjh[k Relationship with the jgs gSa\ crk,a dk LFkku n'kkZ,a
Date of Birth/Age as on Employee Whether residing If' No' state Place of
date of filling form with him/her. Residence
gk¡@Yes ugha@No dLck@Town jkT;@State
1 Priyanka Santosh Kadam 27-03-1996 Spouse Yes
2 Ramesh Yadavrao Kadam 01-01-1968 Father Yes
3 Sai Santosh Kadam 26-01-2016 Child Yes
4 Savita Ramesh Kadam 01-01-1970 Mother Yes
5 Shraddha Santosh Kadam 31-07-2023 Child Yes

d-jk-ch- fuxe vLFkk;h igpku i=k ¼fu;qfDr dh rkjh[k ls 3 eghus rd oS/k½

ESI Corporation Temporary Identity Card (Valid for 3 month from the date of appointment)
uke@Name Santosh Ramesh Kadam
chek la[;k@Ins. No. fu;qfDr dh rkjh[k@Date
15-12-2023
of appointment
'kk[kk dk;kZy; vkS"k/kky; QksVks ds fy, LFkku
Branch Office Dispensary (Space for photograph)

fu;kstd dh dwV la[;k o irk

Employer's Code No. & Address

oS/krk
Validity

X
eSigned using Aadhaar
(Leegality.com - bE0RKT6)
rkjh[k chekÑr O;fDr ds gLrk{kj@vaxwBs dk fu'kku lhy lfgr 'kk[kk izca/kd ds gLrk{kj
Santosh Ramesh Kadam
Dated Signature/T.I. of I.P. Signature of B.M. with seal
Date: Fri Dec 15 17:07:31 IST
2023
 vuq n s ' k
Offer Ref # 3196762
INSTRUCTIONS

1- QkeZ&1 dk izs"k.k d-jk-ch- ¼lk/kkj.k½ fofu;e] 1950 ds fofu;e 11 o 12 ds varxZr fofu;fer fd;k tkrk gSA
Submission of Form-I is governed by regulation 11 & 12 of ESI (General) Regulations, 1950

2- ßdqVqEcÞ ls fdlh chekÑr O;fDr ds fuEufyf[kr lHkh vFkok dksbZ ukrsnkj vfHkizsr gS%&
vFkkZr~%& ¼1½ fookfgrh ¼2½ chekÑr O;fDr ij vkfJr dksbZ /keZt ;k nÙkd vo;Ld vkfJr ckyd] ¼3½ dksbZ ckyd tks chekÑr O;fDr
ds miktZuksa ij iw.kZr% vkfJr gS rFkk tks ¼d½ f'k{kk izkIr dj jgk gS] muds 21 o"Z dh vk;q izkIr dj ysus rd ¼[k½ dksbZ vfookfgr iq=kh]
¼4½ dksbZ ckyd tks fdlh 'kkjhfjd vFkok ekufld vilkekU;rk ;k pksV ds dkj.k f'kfFkykax gS rFkk f'kfFkykaxrk jgus rd chekÑr O;fDr
ds miktZuksa ij iw.kZr% vkfJr gS] ¼5½ vkfJr ekrk&firk] ¼C;ksjs gsrq d-jk-ch- vf/kfu;e] 1948 dh /kkjk 2 ds [kaM 11 dks ns[ksa½A
“Family” means all or any of the following relatives of an Insured Person namely:-

(i) a spouse (ii) a minor legitimate or adopted child dependant upon the I.P.; (iii) a child who is wholly dependant on the
earnings of the I.P. and who is (a) receiving education, till he or she attains the age of 21 years (b) an unmarried daughter;
(iv) a child who is infirm by reason of any physcial or mental abnormality or injury and is wholly dependant on the earnings
of the I.P. so long as the infirmity continues; (v) dependant parents (Please see Section 2 clause 11 of the ESI Act 1948 for
details.

3 igpku&i=k vgLrkUrj.kh; gSA

Identity Card is Non-Transferable.

4- igpku&i=k ds xqe gksus dh fLFkfr esa fu;kstd@'kk[kk izca/kd dks rRdky lwfpr fd;k tk,A
Loss of Identity Card be reported to Employer/Branch Manager immediately.

5- fdlh izdkj dh xyr lwpuk nsus dh fLFkfr esa d-jk-ch- vf/kfu;e] 1948 dh /kkjk&84 ds rgr dkuwuh dk;Zokgh dh tk ldrh gSA
Submission of false information attracts penal action Under Section 84 of ESI Act. 1948.

6- ubZ fu;qfDr dh fLFkfr esa Hkyh&Hkkafr Hkjk gqvk ;g QkeZ fu;qfDr ds nl fnu ds Hkhrj lacaf/kr 'kk[kk dk;kZy; esa vo'; gh izLrqr fd;k
tkuk pkfg,A foyEc dh fLFkfr esa fu;kstd ds fo#) /kkjk&85 ds rgr dkuwuh dk;Zokgh dh tk ldrh gSA
This form duly filled in must reach the concerned Branch Office within 10 days of appointment of an Employee. Delay
attracts penal action under Section 85 of the Act, against employer.

7- chekÑr O;fDr gksus ds ukrs vki o vkids ifjokj ds vkfJrtu fpfdRlk fgrykHk izkIr dj ldsaxsA vU; udn fgrykHk gSa] ¼1½ chekjh
fgrykHk ¼2½ vLFkk;h viaxrk fgrykHk ¼3½ LFkk;h viaxrk fgrykHk ¼4½ vkfJrtu fgrykHk ¼5½ izlwfr fgrykHk ¼efgyk deZpkjh ds fy,½A
As an insured person you and your dependant family membes are entitled to full medical care. The other benefits in cash
include (1) Sickness Benefit (2) Temporary Disablement benefit (3) Permanent disablement Benefit (4) Dependants benefit
and (5) Maternity Benefit (in case of woman employees) subject of fulfillment of contributory cnditions.

8- vf/kd tkudkjh ds fy;s Ñi;k fuxe ds osclkbV dks nsa[ksa ;k 'kk[kk dk;kZy; ;k {ks=kh; dk;kZy; ls laidZ djsaA
For more details please contact website of ESIC at www. esic.org. in. or contact Regional Office or Branch Office.

dsoy 'kk[kk dk;kZy; esa iz;ksx gsrq

For Branch Office Use only

1- chek la[;k vkoaVu dh rkjh[k %

Date of allotment of Ins. No. :_________________________________________

2- vLFkk;h igpku i=k tkjh djus dh rkjh[k %

Date of Issue of T.I.C. :______________________________________________

3- vkS"k/kky; dk uke@la[;k %
Name /No. of Dispensary : ___________________________________________

4- D;k vU;ksU; fpfdRlk O;oLFkk miyC/k gS\ ;fn gkaa] rks mYys[k djsa %
Whether reciprocal Medical arrangements involved. if yes, please indicate :

'kk[kk izcU/kd ds gLrk{kj

Signature of Branch Manager

Ø-la- uke QkeZ Hkjus dh rkjh[k deZpkjh ds lkFk ukrsnkjh D;k muds lkFk jg ;fn ugha] rks vkokl
SI. No. Name dks vk;q@tUe&rkjh[k Relationship with the jgs gSa\ crk,a dk LFkku n'kkZ,a
Date of Birth/Age as on Employee Whether residing If' No, state Place of
date of filling form with him/her. Residence
gk¡@Yes ugha@No dLck@Town jkT;@State
1 Priyanka Santosh Kadam 27-03-1996 Spouse Yes
2 Ramesh Yadavrao Kadam 01-01-1968 Father Yes
3 Sai Santosh Kadam 26-01-2016 Child Yes
4 Savita Ramesh Kadam 01-01-1970 Mother Yes
5 Shraddha Santosh Kadam 31-07-2023 Child Yes