ANNEXURE - II

CONTRACTOR EMPLOYEE GATE PASS APPLICATION FORM

NEW RE-NEW

Token No..:-..
Name of Contractor/Vendor:RAAHAHLR.KMMAR.SAANLDl......
Work area/Dept.: R.0.2LA.S..AGKHALISA...
E.S.I.C No.: 4.4.0.6.T.43.2.3.3..UAN No: L.Q.la.6..A6.3O2.S....
WC POLICY NO. Validity: From.......
Purchase Order No.:/3Sa2303.4.3..Validity: From. ..........To....
Name of Person: (aLRJESH..K.R.BHA.RA.t.J.
Father's/Husband's name: \J.I.NQR.RHA.RAI.J....
Marital Status: -Single/ Married/ Divorce Gender: Mate/Female/Transgender
Category: General/ OBC/ SC/ST Religion:.tH.LN.AH.
Nationality: -.JAM.D.IAN.. Nature of Job: Unskilled/ Semi Skilled/ Skilled/ Highly Skilled
ISMW (Interstate Migrant Workmen): |Yes No

Date of Birth(dd/mm/yyyy):-.Q.d.l.bd.[199.4. Age (in years):-Rk....Blood Group:.Q.t.

Mobile No.49.34.S.8.6.... Emergency Contact No.8.0.S2D..6.3.1O.
Name of Bank:-.S.B.I... Bank Account Number:3..+.l6.S.549.6.I9....
IFSC Code:-.SBIHOQ3.3.2rl......Branch &Branch Address:-..DSLDH...
Present Address: At/ Po:-#ARA-Sl..PAAA. ...Dist.Sbluta. State:-0.DASlai..Pin...3D [s
Permanent Address: At/Po:-BARAHAAA.BUINRL... Dist.:Kushi.nsState:-(L.A...
Pin.274.362

Undertaking:
, the undersigned,hereby certify that details given above are correct &true to the best of my knowledge. I will follow
the code of conduct, all safety &security rules &procedures while working in Hindalco Hirakud Complex. I am aware
that loss/non-return/miss-use of this gate pass shall make me liable for penalties as decided by the competent
authority.

Applicant's signature

Itake full responsibility for the conduct and behaviour of the above person engaged by me for work at Hindalco Hirakud
Complex.

Signature & seal of Contractor

M/s Randhir Kumar Singh

Authorised Signatory
 Annexure -IV

MEDICAL EXAMINATION REQUEST FORM

Pre-Employment Periodic

To
The Medical Officer
Occupational Health Centre
Hindalco, Hirakud Complex

kindly submit the medical report of Sri /Smt.(aRJCSH KR Bharati _S/o Sri.ulNop BAaxati
of M/s. RANDHR KUmo ·nga after conducting medical examination.

*Remarks of the Medical Oficer...

M/s Randhir Kumar Singh

Signature 6fcontractor with Stamp Name &Signature of MedicalOfficer
Authorised Signatory
Date: Date:

Signature of Candidate

Annexure - V

Safety Induction Form

[TO WHOMEVER IT MAY CONCERN]

This is to Certify that Mr. / Sri. / Snt. CoLR 1EKH Ke BHARA L Token No.

Son of W/0, /Mrs.hol Bha kakl whose ESI No is 44DaS1233_of

M/s. RKiS has under gone under safety induction training and handed over
the safety card /diary on dated

Signature of Candidate (Authorized Signatory)

Name Safety Department
Name & Signature of Safety Officer
Date: Date:
 New Form No.l Declaration Form
rofernee)
lo he rsfained y the #nolovur for frfra

EMPLOYEES PROVIDENT FUND ORGANZATION fmp Code

Imployees provident funds scherne, 1952 (paragraph 14 &$7) &

Imployccs pension scheme 1995 (paragraph 24) Cornpany
(Declaration by aperson taking up cmployment in anv cutablishment on which EPE Schemc, 1932 cnd /of EPSI' n pplcae)
Namc of the membcr

Father's Name ( Spouse's Nanme ( )

(Plcasc Tick Whichecver Is Applicable)
Date of Binh (DD/MM/YYYY)
1 Gender: (mle /Fcmale /Iransgender )
MaritalStatus (married /Unarried /widow/divoree)
(a)Lmail |D:

(b) Mobilc No:

7
Whether carlicr a member of Enployces 'providcnt Fund Scheme 1952 Yes
Whether carlher a member of Employces 'Pension Scheme,1995 Yes No
If response to any or both of (7) &(8) above is yes. MANDATORY FILL, UP THE (CoLUMN 9)
a) Universal Account Number(UAN)
b) Previous PF a/c No AP |YD ESTCODE EXTN PF NO.
9
C) Date of cxit from previous cmploymcnt (DD/MM/YYY)
d) Scheme Certificate No (if Issucd
c) Pension P'ayment Order (PPO)No (if Issuecd)
a) Intcrnational Worker: Yes No
b) IfYcs ,State Country OfOrigin (India Name of Other Country)
C
Passport No
d) Validity Of Passport (DD/MMIYYY) to(DD/MM/YYY)
KYC Details: (attach Self attested copies of following KYCs) **
a Bank Account No.& IFS code
b AADIIAR Number (12 Digit)
c) Permancnt Account Number (PAN),If available
UNDERTAKING
) Certifiedthat the Particulars are true to the best of my Knowledge
2) Iauthorize EPFO to use my Aadhar for verification / cKYCpurpose for service delivery
3) Kindly transfer the funds and servicc details, if applicable if applicable, from the previous PF account as declared above to the
present PF Account(The Transfer Would be possible only if the identified KYC details approved by prev ious employer has
bcen verificd by present employer
4) Incase of changes In above details the same Will be intimate to employer at the carliest
Date:
Place Signature of Member
DECLARATION BY PRESENT EMPLOYER
A The member Mr/Ms/Mrs n JO has joincd on and has been allotted PE NumberCheA 2!74
3) In case person was carlier not a member of EPF Scheme,1952 and EPS.1995
(Post allotinent of UAN ) The UAN Allotted for the member is. /OI66j 3362
Please tick the Appropriate Option
The KYC details of the above member in the UAN database
Have not becn uploadcd
Havc becn uploaded bul not approved
Have boen uploaded and approved with DSC
0 lo case hc person was carlier a mennber of EPE SCheme,1952 and EPS. 1995
The aboNe PE accountnunber /UAN ofthe member as DiCItioncd in (a) above has been tagged with his her UAV prevloux meocr ID
declarcd by incnber
Pleass Tick the Apprupriate Opiou
The KYCdctauls of Uc above Cmbes n hc UAN dalabac havc becu appruvcd with digial ignaure ( eruticae au ranaicr ouue
has bcc gchcralcd un poal
A the lDSC o stablihCal ac hol ICgislcicd Wh EPFOhe mKmber has becn nlornicd w lle phy sic al clun Frm liu amaler
of funds tou his pre lous cstablasuxat

Dalc

andhir Kuiar Sungh

Authorised Signatory
 FORM -1Ánnexure IX
NOMINATION AND DECLARATION FORM
(See Rule-3 under payment of Gratuity Rules)

1-Narme of person making nomination (oY) Rh KYBhev

2-Father's/husband's name wihng ahaut

3-Dateofbirth- bl/o992_45ex. Na 5-Marital status- u'h baescHE
6-Address: Permanent: BA DAHAPA DuDHI kySINANAK wtHaY pradeSh 244302.

Ihereby nominate the Person(s)/cancel the nomination made by me previously and nomination
the persons nominated below to receive any amount due to me from the employers in the event to
my death.

Total amount of If the nominee is minor,

share of name, relationship and
Name of the Nominee's Date of
accumulations in address of the guardian
Address credit to be paid who may recessive the
Nominee/nominees relationship Birth
to each nominee amount

MEh clfor/r
Full

1- Certificate that lhave no family and should Iacquire a family hereafter the above nomination shall be
deemed as cancelled.

2-Certificate that my Father/Mother is are dependent upon me.

3- Strikeout whichever is not appficable.

Signature or the thumb impression of the employed person.

CERTIFICATE BY EMPLOYER

Certified that the above declaration and nomination has been signed/thumb impressed before me by
Sri/Srnt/Kum. taiz iga employed in my establishment after he/she has read the
entryfentries have been read over to him/her me and got confirmed by him/her.

Place: Hirakud Signature of the employer or authorized officer.

Date Designation & starmp:
 FORM - 28
(Prescribed under Rule 94 of Orissa Factories Rules, 1950)
NOMINATION FORM

The Manager,
M/s_ A NDh kunv

Dear Sir,

Ihereby require that in the event of my death before resuming work, the balance of my pay due
for the period of leave shall be paid to who is my and
resides at

Signature of applicant
Date:

Employee Name: Lay Jesle ky Bhayt

Father's name:Nd AaMt
Designation APANA Op2E 1OL

Present Address Permanent Address

At:-.d:a.Shel.Rucl.
Po:-..k134u nl.. Po:-.Aude.
Dist.:-.9&nhoatuM. Dist.:-.kkk.Shu. nAe..
Ps:..arlksl Ps:-...

State:-...BDE.S.do......... State:-.catdt%. PaMelaiA

Witness 1 Witness2

Name: Name:

Address: Address:
 Uni ldenaCeion Authority of India
Address.
3lcl d-ia HKÍT, SEI TÍ S/O Vinod 8harati, badahara
bujurg. Dudhi, Kushinagar.
274302 Dudha1, Ultar Pradesh, 274302

4601 1821 3733

1947
www.
1800 300 1947 nelp @unda.gov www uIdas.gov in

Government of India
Girjesh Kumar Bharati
HoH ff DO8:01/01/1997
qhG /Male

4601 1821 3733

Renta
Panda
41444144
q984SSI60.
 SBI - KIOSK BANKING
Identity Card
CiNunber: 89968515725
ACCOunt 37165649679
Number:
IFSC Code: SBINUO13321
First Name: GIRJESH
Middie Name: KUMAR
Last Name: RHARATI
S/O ViNOD BHARATI VIL
Address: BADAHARA BUURG
UDHA!
UIST-KUSHINAGAR
Village Name: DUDHI
PinCode: 274302
MUNIR ALAM
KO Name:
GAURI SHRI RAM
KO Location:
 SIc
EMPLOYEES' STATE INSURANCE CORPORATION
e-Pehchan Card

PERSONAL DETAILS

Name of IP : GIRIJESH KUMAR BHARATI Insurance No. 4406547233

Date of Birth 01/01/1997 UHID NA

Gender : Male UAN : NA

Mobile Number :9934581860 ABHA Number NA

Email ID : NA ABHA Address : NA

Registration Date : 20/10/2023 Aadhaar :NA

REGISTRATION DETAILS

Marital Status Unmarried Name of Father / : VINOD BHARATI

Husband
Type Of Disability NA

Present Address DUBURI,KALINGANAGAR,JAJPUR,Dist:J Permanent Address BADHARA

ajapur (Jajpur),Odisha, 755026 BUZURURG.DUDHAI.Dist:Kush
inagar,Uttar Pradesh,274302

Dispensary / : Duburi, OR (ESIS Disp.) Dispensary : Mahanagar, Lucknow, UP

IMP for IP IMP for Family (ESIS Disp.)

CURRENT EMPLOYER DETAILS

Employer's Code 59001616930000999 Name of Employer Randhir Kumar Singh

No.

Sub Unit's Code : None Date of 08/07/2024

No Appointment

Address of : Lig-37, Maharana Pratap Branch Office : BO - Korba,Branch Office.

Employer Nagar, Korba,Dist:KorbaChhattisgarh4956 E.S.I. Corporation, Vikash
Bhawan, Old Bus Stand. 1st

FAMILY DETAILS

Name Relation Date UHID/ABHA Number ABHA UANI State/District

Is Residing
with of Birth Address Aadhaar
with IP

Page 1 of 2
 Emplovees' Provident Fund Organisation
Printed On 08/07/2024

Approved Member Registration Details

Est ld:CGRAI0021946000
Note :DSCleSign is not required in case of verified
Est Name: RANDHIR KUMAR SINGH

1 Member
Member ld:CGRAI00219460000010383
Name: GIRJESH KUMAR BHARATI

UANPrevious Member 101665868025

Name GIRJESH KUMAR BHARATI

Date of Birth 01-Jan-1997
Date of joining 08-Jul-2024
Marital Status Un-Married
Gender Male

(F)athers/(H)usband's VINOD BHARATI (F)

Nationality Indian

8052076370 e-Mail ID
Mobile
Is Intermational Worker No

MATRIC Monthly EPF Wages as on Joining 8000

Qualification

Disability Type No
Member is from Assam, No
Meghalaya. Nagaland. Nepal
1995.
Note: "means employee is not eligible to become the member of EPS
KYC Details Pending For Digital Signatory
Document Document information Verification
SI No KYC Document Name As Per Document
Number Status

XXNPBO005XX GIRJESH KUMAR BHARATI

1 PAN
XXXXXXXX 3733 VERIFIED
2 AADHAAR GIRJESHKUMAR BHARATI

1/4
 OdishaPolice
Sambalpur

Service Request Receipt

Character Certificate
|RequestType :
|Request No. |245062412159
Name of Applicant : Girjesh Kumar Bharati
Submited To: Hirakud Police Station
Current Status : Registered
Date of Submission l07/07/2024

Oficer-In-Charge
Hirakud PoliceStation
Sambalpur

Thisisacomputergenerateddocumentanddoesnotrequireanysignature.Crime Page I of 1

and Criminal Tracking Network and Sysems(CCTNS) Date Of Printing: 07/07/2024