Latest

Passport size
Photograph
with
Blue Background
Signature within the Box

DOMAIN ID :
EMPLOYEE NAME : Kalpana Santosh Panda

PHONE NO: MOB. : 7208401493

BLOOD GROUP*: B+ DOB : 02/04/1988
CASTE : Open PAN: CBCPP9503J

BANK A/C, BANK NAME & IFSC CODE : 50100211678531, HDFC BANK
IFSC- HDFC0000276

EMERGENCY CONTACT DETAILS (Name & Number) :

Santosh Panda & 9987757827

DATE OF JOINING( DD/MM/YY): 21/10/2024 EMPLOYEE’S HEIGHT (cms.)* : 4.10 inch

IDENTIFICATION MARK : WEDDING DATE : (25/02/2012)

AADHAR CARD NO. : 271921969656 MERITAL STATUS: Married

UAN/PF NO. :
101198366819 ESIC NO. : 3414100747
PRESENT ADDRESS : :_ Shiv Shardha Bldg. Rno.101, 1st floor
Nr. Noor Masjid, 2nd Rabodi, Thane (w)
PERMENENT ADDRESS : : Same As Above

Family Background (Please include details of Parents, Spouse & children) Mandatory

Date Of Birth
Name Relationship Gender
(YYYY- MM-DD)

Dayanidhi Panda Father in law Male 12/07/1960

Urmila Panda Mother in law Female 01/06/1964
Santosh Panda Husband Male 12/07/1983
Jagdish S Panda Child 1 Male 19/01/2014
Child 2
 ACADEMIC RECORD (Starting from Xth Class. Original Certificates will be required at the time of joining)

From To Degree/ Diploma

College/ University
MM/YY MM/YY Completed
S.S.C 2003 Mumbai University
H.S.C 2005 Mumbai University
B.COM 2008 Degree
Mumbai University

WORK EXPERIENCE RECORD (Start with current Employment)

Duration Total Name and Address of the Basic Nature Designation Salary Reasons
Exp. In Organization of Duties On joining On Joining for Leaving
From To months
MM/YY MM/YY On Leaving On Leaving
21/10/2017 02/10/2023 6yrs Datamark Pvt.Ltd Process Associate Process Associate Better
Prospectus
2,10 Lpa
Better
01/11/2010 06/01/2012 2yrs Process Associate Process Associate
3i Infotec Pvt ltd 1.70 Lpa Prospectus

DECLARATION
I declare that the information given in this personal data form and the certificates accompanying is correct and
complete to best of myknowledge and belief. I also understand that atany stage Imay be asked to provide
adequate justification of the facts stated above, and I would do so when called for. I accept the job and position given
to me in all respect and will strive to work towards company core values and help to achieve its vision and mission.

Date: 18/10/2024
Place: Mumbai
Signature or Left / Right hand thumb impression of the Employee
 Declaration Form
(To be retained by the Employer for future reference)

Employees’ Provident Fund Organization

THE EMPLOYEES’ PROVIDENT FUNDS SCHEME, 1952 (PARAGRAPH-34 & 57)
&
THE EMPLOYEES’ PENSION SCHEME, 1995 (PARAGRAPH-24)
DECLARATION BY A PERSON TAKING UP EMPLOYMENT IN AN ESTABLISHMENT ON WHICH EMPLOYEES’ PROVIDENT FUND SCHEME,
1952 AND/OR EMPLOYEES’ PENSION SCHEME, 1995 IS APPLICABLE.

(PLEASE GO THROUGH THE INSTRUCTIONS)

1) NAME (TITLE) K A L P A N A S A N T O S H P A N D A
MR . MS. MRS.
(PLEASE TICK)

D D M M Y Y Y Y
2) DATE OF BIRTH 0 2 0 4 1 9 8 8

3) FATHER’S/ MR .
HUSBAND’S NAME

4) RELATIONSHIP IN RESPECT OF (3) ABOVE FATHER HUSBAND

(PLEASE TICK)

5) GENDER MALE FEMALE TRANSGENDER

(PLEASE TICK)

6) MOBILE NUMBER
(IF ANY)

7) EMAIL ID (IF ANY)

8) WHETHER EARLIER A MEMBER OF THE EMPLOYEES’ PROVIDENT FUND SCHEME, 1952?

(PLEASE TICK) YES NO
9) WHETHER EARLIER A MEMBER OF THE EMPLOYEES’ PENSION SCHEME, 1995?
(PLEASE TICK) YES NO
IF RESPONSE TO ANY OR BOTH OF (8) & (9) ABOVE IS YES, THEN MANDATORILY FILL UP THE PREVIOUS EMPLOYMENT DETAILS
AT (10,11&12):
Page 1 of3
 A. PREVIOUS EMPLOYMENT DETAILS
10) THE DETAILS OF THE UNIVERSAL ACCOUNT NUMBER (UAN) OR PREVIOUS PFMEMBER ID:
UAN 1 0 1 1 9 8 3 6 6 8 1 9
OR
PREVIOUS PF MEMBER ID REGION OFFICE ESTABLISHMENT EXTENSIO ACCOUNT
CODE CODE ID N NUMBER

11) DATE OF EXIT FOR PREVIOUS D D M M Y Y Y Y

MEMBER ID (DD/MM/YYYY)

12) (A) IF SCHEME CERTIFICATE ISSUED FOR PREVIOUS EMPLOYMENT, THEN SCHEME CERTIFICATE NUMBER:
(B) IF PENSION PAYMENT ORDER (PPO) ISSUED FOR PREVIOUS EMPLOYMENT, THEN PPO NUMBER:

B. OTHER DETAILS

13) INTERNATIONAL WORKER YES NO

(PLEASE TICK)

IF THE REPLY TO (13) ABOVE IS YES, THEN ENTER THE DETAILS IN 13(A), 13(B) & 13(C):
13(A) COUNTRY OF ORIGIN (Please Tick)
INDIA OTHER THAN INDIA (IF YES, PLEASE
MENTION NAME OF THE COUNTRY)

13(B) PASSPORT NUMBER

13(C) PASSPORT VALID FROM D D M M Y Y Y Y

To D D M M Y Y Y Y

14) EDUCATIONAL ILLITERATE

NON-
MATRIC
SENIOR
GRADUATE
POST
DOCTOR
TECHNICAL/
QUALIFICATION MATRIC SECONDARY GRADUATE PROFESSIONAL
(PLEASE TICK)

15) MARITAL STATUS MARRIED UNMARRIED WIDOW/ WIDOWER DIVORCEE

(PLEASE TICK)

IF YES, TICK THE CATEGORY

16) SPECIALLY ABLED YES NO
LOCOMOTIVE VISUAL HEARING
(PLEASE TICK)

Page 2 of3
17) K YC DETAILS KYC DOCUMENT TYPE NAME AS ON KYC DOCUMENT NUMBER REMARKS, IF ANY
BANK ACCOUNT-1* Kalpana Santosh Panda 50100211678531 HDFC0000276
NPR/AADHAAR Kalpana Santosh Panda 271921969656

PERMANENT ACCOUNT Kalpana Santosh Panda

NUMBER (PAN) CBCPP9503J
PASSPORT - EXPIRY DATE
DRIVING LICENCE - EXPIRY DATE
ELECTION CARD Kalpana Santosh Panda RCT5711460

RATION CARD
ESIC CARD
* Mandatory Field (NOTE: BANK ACCOUNT NUMBER (ALONG WITH IFSC CODE) IS MANDATORY. YOU
ARE HOWEVER ADVISED TO PROVIDE ALL KYC DOCUMENTS AVAILABLE WITH YOU IN ADDITION TO MANDATORY KYCS TO

C. UNDERTAKING:
A. I CERTIFY THAT ALL THE INFORMATION GIVEN ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE AND BELIEF.
B. IN CASE, EARLIER A MEMBER OF EPF SCHEME, 1952 AND/OR EPS, 1995,
(I) I HAVE ENSURED THE CORRECTNESS OF MY UAN/ PREVIOUS PF MEMBER ID.
(II) THIS MAY ALSO BE TREATED AS MY REQUEST FOR TRANSFER OF FUNDS AND SERVICE DETAILS IF APPLICABLE FROM
THE PREVIOUS ACCOUNT AS DECLARED ABOVE TO THE PRESENT P.F. ACCOUNT. (THE TRANSFER WOULD BE POSSIBLE
ONLY IF THE IDENTIFIED KYC DETAILS APPROVED BY PREVIOUS EMPLOYER HAS BEEN VERIFIED BY PRESENT
EMPLOYER USING HIS DIGITAL SIGNATURE CERTIFICATE).
(III) I AM AWARE THAT I CAN SUBMIT MY NOMINATION FORM THROUGH UAN BASED MEMBER PORTAL.

DATE:
PLACE: SIGNATURE OF MEMBER
DECLARATION BY PRESENT EMPLOYER
A. THE MEMBER Mr./Ms./Mrs. ..Kalpana Santosh Panda.... HASJOINED ON.21/10/2024.....AND HAS BEEN ALLOTTED PF
MEMBER ID THTHA14944720000010516
…………………………………………...
B. IN CASE THE PERSON WAS EARLIER NOT A MEMBER OF EPF SCHEME, 1952 AND EPS, 1995:
(POST ALLOTMENT OF UAN) THE UAN ALLOTTED FOR THE MEMBER IS …………………………
PLEASE TICK THE APPROPRIATE OPTION:
THE KYC DETAILS OF THE ABOVE MEMBER IN THE UAN DATABASE
□ HAVE NOT BEEN UPLOADED
□ HAVE BEEN UPLOADED BUT NOT APPROVED
□ HAVE BEEN UPLOADED AND APPROVED WITH DSC
C. IN CASE THE PERSON WAS EARLIER A MEMBER OF EPF SCHEME, 1952 AND EPS, 1995:
THE ABOVE MEMBER ID OF THE MEMBER AS MENTIONED IN (A) ABOVE HAS BEEN TAGGED WITH HIS/HER UAN/PREVIOUS
MEMBER ID AS DECLARED BY MEMBER.
PLEASE TICK THE APPROPRIATE OPTION:-
□ THE KYC DETAILS OF THE ABOVE MEMBER IN THE UAN DATABASE HAVE BEEN APPROVED WITH DIGITAL
SIGNATURE CERTIFICATE AND TRANSFER REQUEST HAS BEEN GENERATED ON PORTAL.
□ AS THE DSC OF ESTABLISHMENT ARE NOT REGISTERED WITH EPFO, THE MEMBER HAS BEEN INFORMED TO FILE
PHYSICAL CLAIM (FORM-13) FOR TRANSFER OF FUNDS FROM HIS PREVIOUS ESTABLISHMENT.

DATE: SIGNATURE OF EMPLOYER WITH SEAL OF ESTABLISHMENT

Form -2
FORM 11 ( Revised)

THE EMPLOYEES’ PROVIDENT FUNDS SCHEME,1952 (Paragraph 34) THE EMPLOYEES’ FAMILY

AND PENSION SCHEME, 1971 (Paragraph 19) Declaration by a person taking up employment in

an establishment in which
the Employees’ Provident Funds & Family Pension Fund Scheme enforce

Kalpana Santosh Panda

I.......................................................................S/o/W/o/Daughter Santosh Panda
of..................................................
(NAME OF EMPLOYEE)
do hereby solemnly declare that :-

(a) I was employed in M/s.........................................................……................................................

Datamark Pvt, ltd, 201 Thane 1 DIL complex Kapurwadi Thane 400601
(NAME AND FULL ADDRESS OF THE ESTABLISHMENT)

and left service on 02/10/2023..prior to that, I was employed in..Datamark Pvt ltd...................................................
( DATE ) (NAME AND FULL ADDRESS
..........................................................................from.......................................to......................................
OF THE ESTABLISHMENT) ( DATE ) ( DATE )

(b) I was member of ...................................................................................Provident Fund and also/but

( Name of Trust or R. P. F. C.)
not of the Pension Fund from.....................................to ........................................ and my account
( DATE ) ( DATE )
number (s) was/were......………………........
( PF No. )
(c) I have/have not withdrawn the amount of my Provident Fund/Pension Fund.

(d) I have/have not drawn any superannuation benefits in respect of my past service from any employer. (e) I have/have not never

been a member of any Provident Fund and/or Pension Fund.

(f) I am drawing/not drawing Pension under EPS 95. (g) I am a holder/not holder

of scheme Certificate. (h) Scheme certificate surrendered/not surrendered.

18/10/2024
Date............................. Signature or left hand thumb impression of the
employee.

(To be filled by the employer only when the person employed had not already been a member of the
Employees’ Provident Fund)

Shri/Smt………….....................................................................is appointed as.................................................

(NAME OF EMPLOYEE) (DESIGNATION)
in M/s……………….............................................................................………with effect from..........................
(NAME OF THE FACTORY/ESTABLISHMENT) (DATE OF APPOINTMENT)

P.F. Account Number ………………………….

Date............................ Signature of the Employer/Manager or Other Authorised Officer

Form -2
 FORM 2 (Revised)

NOMINATION AND DECLARATION FORM FOR UNEXEMPTED/

EXEMPTED ESTABLISHMENTS

Declaration and Nomination Form under the Employees’ Provident Funds and
Employees’ Pension Scheme

(Paragraphs 33 & 61 (1) of the Employees Provident Fund Scheme, 1952 and Paragraph 18 of the Employees’ Pension scheme, 1995)

1. Name (in Block letters) : MRS. KALPANA SANTOSH PANDA

2. Father’s/Husband’s Name : SANTOSH D PANDA

3. Date of Birth : 02/04/1988

4. Sex : FEMALE
5. Marital Status : MARRIED
6. Account No. : 50100211678531
7. Address : Permanent : Shiv Shardha Bldg. Rno. 101, 1st Floor, Nr. Noor Masjid,2nd Rabodi, Thane (w)400601
Temporary : Same as above

PART – A (EPF)
I hereby nominate the person(s) /cancel the nomination made by me previously and nominate the person(s) mentioned below
to receive the amount standing to my credit in the Employees’ Provident Fund in the event of my death :

Name of
nominee/ Address Nominee’s relation- Date of Total amount of share of If the nominee is a minor,
nominees ship with the member Birth Accumulations in Provi- name & relationship & address
dent Fund to be paid to of the guardian who may
each nominee receive the amount during
the minority of nominee

1 2 3 4 5 6

Santosh D Panda shiv shardha bldg. Husband 12/07/1983 100%

Rno.101, 1st flr,
2nd Rabodi,
Thane (w) 400601

1 * Certified that I have no family as defined in para 2(g) of the Employees’ Provident Fund Scheme, 1952 and should
I acquire a Family hereafter, the above nomination should be deemed as cancelled.

2 * Certified that my father/mother is/are dependent upon me.

Signature or thumb impression of the subscriber

*Strike out whichever is not applicable

Form -2
 Part B (EPS) (Para 18)
I hereby furnish below particulars of the members of my family who would be eligible to receive widow/children pension
in the event of my death.

S.No. Name of the family Address Date of Birth Relationship with the member
member

1 2 3 4 5

1 Santosh Panda Shiv Shardha bldg. 12/07/1983 Husband

Jagdish Panda Rno.101, 1st flr, Children
2 2nd Rabodi, 19/01/2014
Thane (w) 400601
3

** Certified that I have no family, as defined in para 2(vii) of Employees’ Pension Scheme, 1995 and should I acquire a family
hereafter I shall furnish particulars thereon in the above form.

I hereby nominate the following person for receiving the monthly widow pension (admissible under para 16 2(a)(i) and (ii)
in the event of my death without leaving any eligible family member for receiving Pension.

Name and Address of the Nominee Date of Birth Relationship with the member

1 2 3

1.

2.

3.

4.

Date : 18/10/2024
Signature or thumb impression
Place : Mumbai of the subscriber
**Strike out whichever is not applicable.

CERTIFICATE BY EMPLOYER
Certified that the above declaration and nomination has been signed/thumb impressed before me by Shri/Smt./Kum.

employed in my establishment after he/she has read the entries/entries have been read over to him/her

by me and got confirmed by him/her.

Place :
Signature of the employer or other
Authoried Officers of the Establishment.

Designation
Dated the :

Name & Address of the Factory/

Establishment or Rubber Stamp Thereon

Form -2
 Kalpana Santosh Panda

Santosh Panda

02/04/1988
Female
Married
kalpanapanda0288@gmail.com
7208401493

101198366819

THTHA14944720000010516
02/10/2023

50100211678531 & HDFC0000276

271921969656
CBCPP9503J

18/10/2024
Mumbai
 EMPLOYEES’ STATE INSURANCE CORPORATION
FORM-1

To be filled in by the employee after reading instructions overleaf. Two Postcard Size photographs are to be
attached with this form. This form is free of cost.

(A) INSURED PERSON‟S PARTICULARS (b) EMPLOYER‟S PARTICULARS

1. Insurance No. Employer‟s Code
2 Name (in block No.
letters) KALPANA SANTOSH PANDA
10. Date of Day Month Year
Father‟s/Husband‟s SANTOSH D PANDA Appointment
Name 11. Name & Address of the Employer
Date of Birth D M Y Marital M/U/W
Status

02 04 1988 6.Sex M/F

7. Present Address 8. Permanent Address 12. In case of any previous employment
_ Bldg. Rno. 101
Shiv Shardha Same as please fill up the details as under:-
1st, flr, nr. noor masjid, 2nd a) Previous Ins.No.
Rabodi Thane (w) 400601
b) Emplr‟s Code No.

Pin Code ……………………………

400601 Pin Code …………………………… C) Name & address of the Employer

e-mail address e-mail address

kalpanapanda0288@gmail.com
Branch Office Dispensary
e-mail address

(C) Details of Nominee u/s 71 of ESI Act 1948/Rule 56(2) of ESI (Central) Rules, 1950 for
payment of cash benefit in the event of death.
Name Relationship Address
Santosh Panda Husband Shiv Shardha Bldg. Rno. 101,1st flr, nr noor masjid 2nd rabodi thane (w)

I hereby declare that the particulars given by me are correct to the best of my knowledge and belief. I
undertake to intimate the Corporation any changes in the membership of my family within 15 days of such
change.

Counter signature by the employer

Signature/T.I.of IP

Signature with Seal

(D) FAMILY PARTICULARS OF INSURED PERSON

Sl. Name Date of Birth/ Age Relationship with Whether If‟No‟, state place of
No. as on date of the Employee residing with Residence
filling form him/her?
Town State Yes No
1. Santosh Panda 12/07/1983/ 40 Husband
2. Jagdish Panda 19/01/2014 / 10 Son
3.
4.
5.
6.
………………..………………………………………………………………………………………………………………………………………………………………

ESI Corporation (Valid for 3 months from the date of appointment)

Temporary Identity Card

Name

Ins.No. Date of appointment

Space for photograph

Branch Office Dispensary

Employer‟s Code No. &

Address

Validity:

Dated: Signature/T.I. of I.P Signature of B.M. with Seal

1. Submission of Form-1 is governed by regulations 11 & 12 of ESI (General) Regulations, 1950.
 2. “Family” means all or any of the following relatives of an Insured Person namely:-

(i) A spouse (ii) a minor legitimate or adopted child dependant upon the I.P;(iii) a child who is wholly
dependant on the earnings of the I.P. and who is (a)receiving education, till he or she attains the age of
21 years (b)an un married daughter; (iv) a child who is infirm by reason of any physical or mental
abnormity or injury and is wholly dependant on the earnings of the I.P. so long as the infirmity
continues; (v) dependant parents (Please see Section 2 clause 11 of the ESI Act 1948 for details).
3. Identity Card is Non-transferable.
4. Loss of Identity Card be reported to Employer/Branch Manager immediately.
5. Submission of false information attracts penal action under Section 84 of ESI Act, 1948.
6. This form duly filled in must reach the concerned Branch office within 10 days of appointment of an
Employee. Delay attracts penal action under Section 85 of the Act, against employer.

7. As an Insured person you and your dependent family members are entitled to full medical care. The
other benefits in cash include (1) sickness Benefit (2) Temporary Disablement benefit (3) Permanent
disablement Benefit (4) Dependents benefit and (5) Maternity Benefit (incase of women employees
subject to fulfillment of contributory conditions.
8. For more details Please Visit website of ESIC at WWW.esic.nic.in or www.esickar.gov.in contact
Regional office or Branch Office.

FOR BRANCH OFFICE USE ONLY

1. Date of Allotment of Ins. No.
2. Date of issue of TIC :
3. Name/ No. of Disp :
4. Whether reciprocal Medical arrangements involved? If yes, please indicate :

Signature of Branch Manager

Sl. Name Date of Birth/Age Relationship Whether If „No‟, state place

No. as on date of with the residing with of Residence
filling form Employees him/her?
Yes No Town State
1
2
3
4
5
6
 Payment of Gratuity (Central)
Rules FORM 'F'
See sub-rule (1) of Rule 6
Nomination

To,
(Give here name or description of the establishment with full address)
Shiv shardha bldg. Rno.101, 1st flr, Nr. Noor Masjid, 2nd Rabodi Thane (w) 400601

I, Shri/Shrimati/Kumari Kalpana Santosh Panda

(Name in full here)
whose particulars are given in the statement below, hereby nominate the person(s) mentioned below to
receive the gratuity payable after my death as also the gratuity standing to my credit in the event of my
death before that amount has become payable, or having become payable has not been paid and direct
that the said amount of gratuity shall be paid in proportion indicated against the name(s) of the nominee(s).
2. I hereby certify that the person(s) mentioned is/are a member(s) of my family within the meaning of
clause
(h) of Section 2 of the Payment of Gratuity Act, 1972.
3. I hereby declare that I have no family within the meaning of clause (h) of Section 2 of the said
Act.

4 (a) My father/mother/parents is/are not dependent on

me.
(b) My husband's father/mother/parents is/are not dependent on my husband.
5. I have excluded my husband from my family by a notice dated the
to the controlling authority in terms of the proviso to clause (h) of Section 2 of the said Act.
6. Nomination made herein invalidates my previous
nomination.

Nominee(s)

Name in full with full Relationship with Age of Proportion by which

address of nominee(s) the employee nominee the gratuity will be
shared

(1) (2) (3) (4)

1. Santosh Panda Husband 40 100%

2.
3.

Statement
1. Name of employee infull Kalpana Santosh Panda
2. Sex Female

3. Religion Hindu
4. Whether unmarried/married/widow/widower Married
5. Department/Branch/Section where employed
6. Post held with Ticket No. or Serial No., if any
7. Date of appointment
 8. Permanent address:
Village Thane Thana Thane Sub-division
Post Office Shreerang school District State Maharashtra

Place: Mumbai
Signature/Thumb-impression of the
Employee
Date: 18/10/2024

Declaration by Witnesses

Nomination signed/thumb-impressed before me

Name in full and full address of witnesses. Signature of Witnesses.
1. 1.

2. 2.

Place:
Date:

Certificate by the Employer

Certified that the particulars of the above nomination have been verified and recorded in this establishment.
Employer's Reference No., if any Signature of the employer/Officer authorised
Designation

Date: Name and address of the establishment or

rubber stamp thereof

Acknowledgement by the Employee

Received the duplicate copy of nomination in Form 'F' filed by me and duly certified by the employer.

Date: Signature of the Employee

Note.—Strike out the words/paragraphs not applicable.

 FORM NO. 12C
(See Rule 26B)
Form for sending particulars of income under section 192 (2B) for the year ending
31st March 2010

1 Employee code :
2 Name of employee : Kalpana Santosh Panda
3 Address of the employee: Shiv Shardha Bldg. Rno.101, 1st floor, 2nd Rabodi, Thane (w) 400601

4 Permanent account no. (Mandatory): CBCPP9503J

5 Residential status:
6 Particulars of income under any head of income other than "salaries" (not being a loss under
any such head other than loss under the head "income from house property") received in the
financial year.
Amount (Rs.)
(I) Income / loss from house property *
(in case of loss, enclose computation, proof’s thereof)
Date of housing loan availed...................
Date of possession ………………………….
(II) Profits & gains of business or profession
(III) Capital gains
(IV) Income from other sources
(A) Dividends
(B) Interest
(C) Other income (specify)
7 Aggregate of sub-items (I) to (IV) of item 6
8 Tax deducted at source [enclose certificate(s)
Issued under section 203]

Place: Mumbai
Date: 18/10/2024 Signature of the employee

¾ If let out, attach computation of loss on house property.

¾ Self-occupation declaration: - I hereby further declare that the ownership of property whose
address is mentioned above is in my name & under self-occupation. No income is derived
from the above said premises.

Verification

I .................................................................................
Kalpana Santosh Panda do hereby declare that what is stated
above is true to the best of my knowledge and belief.

Verified today, the....................day

18 of ..............................200
10 2024....

Place: 18/10/2024
Date: Mumbai Signature of the employee