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    <td align="center"><h2>Return of Members Leaving Services During the Month of</h2>
                      <h4> The Employees' Provident Fund Scheme, 1952 [Paragraph 36(2)(b)]</h4> 
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    <td>&nbsp;</td>
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    <td><table width="175" border="0" align="left" cellpadding="0" cellspacing="0" class="border">
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        Name & Address of the<br />
		Factory / Establishment<br />
        with Code No./ DL
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    <td>&nbsp;</td>
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    <td><table width="990" border="1" cellspacing="0" cellpadding="2">
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        <td align="center" bgcolor="#666666">Sl. No.</td>
        <td align="center" bgcolor="#666666">Account No.</td>
        <td align="center" bgcolor="#666666">Name if the Member <br />
          (in Block Letters)</td>
        <td align="center" bgcolor="#666666">Father's Name<br />
          or Husband's Name<br />
          in Case of Married Women</td>
        <td align="center" bgcolor="#666666">Date of <br />
          Leaving Services</td>
        <td align="center" bgcolor="#666666">Reasons for Leaving Service</td>
        <td align="center" bgcolor="#666666">Remarks</td>
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        <td align="center" valign="top">1</td>
        <td align="center" valign="top">2</td>
        <td align="center" valign="top">3</td>
        <td align="center" valign="top">4</td>
        <td align="center" valign="top">5</td>
        <td align="center" valign="top">6</td>
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    <td>&nbsp;</td>
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    <td>Certified that the casualty has been noted in ledger card of Member</td>
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    <td>&nbsp;</td>
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        <td width="105">Clerk</td>
        <td width="103">H.C.</td>
        <td width="110">A.A.O.</td>
        <td width="48">Dated</td>
        <td width="110"><select style="width:90px;" name="select" id="select">
        <option>01/05/2012</option>
        </select></td>
        <td width="24">20</td>
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    <td>&nbsp;</td>
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    <td><table width="990" border="1" cellspacing="0" cellpadding="3">
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        <td width="353"><strong>Please state whether the member is</strong></td>
        <td width="396">&nbsp;</td>
        <td width="241">&nbsp;</td>
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        <td>
          <ul>
            <li>retiring according to 69(1) of the Scheme</li>
            <li>leaving India for permanent settlement abroad</li>
            <li>retrenched</li>
            <li>ordinarily dismissed/dismissed, </li>
            <li>discharged</li>
            <li>resign from or leaving service </li>
            <li>taking up employment elsewhere (the name and address of the new employer should be stated).</li>
            <li>dead</li>
            </ul>
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        <td align="left" valign="top"><table width="390" border="0" align="left" cellpadding="0" cellspacing="0">
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            <td align="left" valign="top"><strong>Note : </strong>in case of discharge from service, the following certificate should be filied.</td>
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            <td height="15">&nbsp;</td>
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            <td align="left" valign="top">Certified that the member mentioned at S. No. 
              <input style="width:60px" type="text" name="textfield2" id="textfield" /></td>
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            <td>Shri 
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              was paid/unpaid</td>
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            <td>retrenchment compensation of Rs. 
              <input style="width:120px" type="text" name="textfield4" id="textfield3" />
              Under the Industrial Disputes Act, 1947.</td>
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            <td width="379">&nbsp;</td>
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            <td align="right" valign="middle">Signature of the Employer or Other Authorised Officer/ Stamp of the Factory/ Establishment</td>
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            <td width="241" align="right">Signature of the Employer</td>
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    <td>&nbsp;</td>
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