FORM 10-C PENSION

EMPLOYEES PENSION SCHEME 1995

form to be used by a member of employees pension scheme 1995 for claiming withdrawal benefit only

Inward No.

Name of the Member :

Fathers Name: Husband Name:

Name and Address of the Factory / Establishment in which the Member was last employed :

Code No. :

Account No. :

Reasing for Leaving of services & Date of Leaving :

Full Postal Address
Shri / /Smt / Kumari
S/o , D/o , W/o :

MODE OF REMITTANCE

By Postal Money Order at my Cost to the Address giving against item no.7

By Account Payee cheque sent Direct for credit to my SB A/c (Scheduled/Bank/PO) under inmitation to me

Name of the Bank Branch Full address of the Branch

Certified that the Particulars are the true to the best of my Knowledge

Date :

Signature or left thumb impression