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<title>Form 5</title>
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    <td>&nbsp;</td>
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    <td align="center"><h2>Return of Employees Qualifying for Membership of the Employees'<br />
Provident Fund for the Forst Time During the Month of</h2>
<h4>The Employees' Provident Fund Scheme, 1952 [Para 36(2)(a)]</h4>
<h4>Employees' Pension Scheme, 1955 [Paragraph 20(4)]</h4>
<h5>To be sent to the Commissioner with Form 2 (EPF & FPF)</h5>
</td>
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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
        </td>
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    </table></td>
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    <td>&nbsp;</td>
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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">Age/ Date of Birth</td>
        <td align="center" bgcolor="#666666">Sex</td>
        <td align="center" bgcolor="#666666">Date of Eligibility of Membership</td>
        <td align="center" bgcolor="#666666">Total Period of previous Service (Excluding Period of Breaks) as on the date of Joining the Fund</td>
        <td align="center" bgcolor="#666666">Remarks</td>
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    <td class="certified">Certified that the casualty has been noted in ledger card of Member</td>
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    <td align="left" valign="top"><table width="158" border="0" align="left" cellpadding="0" cellspacing="0">
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        <td class="text-box" width="56">Date :</td>
        <td class="text-box" width="102"><select style="width:90px;" name="select" id="select">
          <option>01/05/2012</option>
        </select></td>
        </tr>
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        <td width="663" align="left" valign="top" class="text-box" style="border-right:1px solid #000;"><strong>Note : </strong>
          <br />
          Please funish details of the membership in the remarks column. If employee was a member of employees' Provident Fund and Employees' Family Pension Scheme before Joining Yourself/ Factory, i.e., Account Number and / or the name and particulars of the last employer. </td>
        <td width="327" align="left" valign="top" class="text-box">Signature of the Employer or any other Authorized Official of the Factory/ Establishment<br />
stamp of the Factory / Establishment</td>
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