Contribution card for employees other than monthly paid employees for the period from.......…………….........to ............………………………………………
1. | Account No. ......................................................................................... |
2. | Name (in block capitals)....................................................Surname........................................ |
3. | Caste....................................................................................................................... |
4. | Sex.......................................................................................................................... |
5. | Date of birth as given in Form 2.............................................................................. |
6. | Occupation.............................................................................................................. |
7. | Father’s name......................................................................................…………… |
8. | Husband’s name.................................................................................…………… |
| (for married woman only) |
9. | Marital status.......................................................................................……… |
| (whether bachelor, spinster, married, widow or widower) |
10. | Permanent Address.........................…………. |
| Village................................., Thana......................................, Taluk/Sub-Division...................... District......................, State....................... |
11. | Signature or left hand thumb impression of member........................…………………… |
12. | Signature of person preparing the card....................................... |
13. | Signature of the Manager of the factory or other establishment ........................……. |
14. | Registered Number of the factory or other establishment.................................…….. |
Particulars of employment | |
Registered number of factory or other establishment | Duration of Employment | Remarks | Initials of the employer’s authorised clerk | |
From | To | | |
|
The employer’s and member’s contribution should be shown separately for each week | Employer’s/ member’s total amount refunded | Week | Week | Week | Week | Week | Week | |
1 | 2 | 3 | 4 | 5 | 6 | |
Week | Week | Week | Week | Week | Week | Week | Week | Week | |
7 | 8 | 9 | 10 | 11 | 12 | 13 | 14 | 15 | |
Week | Week | Week | Week | Week | Week | Week | Week | Week | |
16 | 17 | 18 | 19 | 20 | 21 | 22 | 23 | 24 | |
Week | Week | Week | Week | Week | Week | Week | Week | Week | |
25 | 26 | 27 | 28 | 29 | 30 | 31 | 32 | 33 | |
Week | Week | Week | Week | Week | Week | Week | Week | Week | |
34 | 35 | 36 | 37 | 38 | 39 | 40 | 41 | 42 | |
Week | Week | Week | Week | Week | Week | Week | Week | Week | |
43 | 44 | 45 | 46 | 47 | 48 | 49 | 50 | 51 | |
Week | | | | | | | | | | |
52 | | | | | | | | | | |
Total Contribution of the employer | Rs. np. | Signature of the employer’s Head Clerk or any Authorised Clerk Checked and found correct | |
Total Contribution by the member | | Authorised official of the Office of the Commissioner. | |
Grand Total Amount refunded | | | |
