FORM 1 Exemption under paragraph 27 of the Scheme I hereby apply for exemption from the operation of all or the following provisions of the Scheme: (a) ................... (b) ................... (c) ................... (d) ................... (e) ................... 1. Name...................................................................... (In block letters) 2. Occupation........................................................... 3. Sex............................................................................ 4. Religion................................................................... 5. Fathers name.................................................................................................... 6. Husbands name (for married woman only)....................................... 7. Permanent Address......................................................................................... 8. Details of the Provident Fund, gratuity or old age pension
I declare that all the particulars stated above are true to the best of my knowledge and belief. Dated........................... The...........................20 Signature or left hand thumb impression in case of both female and male members of the fund |
Certified that the above declaration has been signed by................................employed in.................................................before me and that he/she is getting the benefits of provident fund, gratuity or old age pension as above. Dated............................ The............................20 Signature of the manager or other authorised officer of the Factory/ Establishment Registered No. of the Factory/Establishment |
Here give the name and address of the factory or other establishment in which employed. | 
