PERSONAL DATA FORM

Please paste your recent Passport Size

Photograph

Name :

Position :

Division :

Emp. Code :

Date of Joining :

We invite you to be a part of S S Kothari Mehta & Co.

S S KOTHARI MEHTA & CO.

CHARTERED ACCOUNTANTS
Plot No. 68, Okhla Phase-III,
New Delhi – 110020
Phone No: +91-11-4670 8888
Fax No: +91-11-6662 8889
Email Id: [email protected]
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Personal Particulars

Full Name :

Present Address :

Permanent Address :

Contact Number : Mobile No:

Resident Telephone No:

Alternate No:

Email Id :

Gender :

Date of Birth :

Place of Birth :
Married – If Yes then mention date of anniversary
Marital Status :

Un-married

PAN No :

Religion :

Nationality :

Blood Group :

Height & Weight :

Major Illness (if any) :

Have you been involved in any

court proceedings? If yes, :
provide details

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Academic Qualification

Examination : Secondary School Examination (10th)

University/ Board :

Name of School/ College :

Year of Passing :

Marks Obtained :

Percentage :

Examination : Senior School Certificate Examination (12th)

University/ Board :

Name of School/ College :

Year of Passing :

Marks Obtained :

Percentage :

Examination : Graduation

Stream :

University/ Board :

Name of School/ College :

Year of Passing :

Marks Obtained :

Percentage :

Chartered Accountancy Marks Obtained Attempt Year

CA Inter Group I

Group II

CA Final Group I

Group II

Examination : Others

Stream :

3
University/ Board :

Name of School/ College :

Year of Passing :

Marks Obtained :

Percentage :

Previous Employment Details:-

Name of the Firm/Company :

Place :

From (Period) :

To (Period) :

Name of the Firm/Company :

Place :

From (Period) :

To (Period) :

Name of the Firm/Company :

Place :

From (Period) :

To (Period) :

Family Particulars:-

Name :

Date of Birth :

Relation :

Occupation :

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Name :

Date of Birth :

Relation :

Occupation :

Name :

Date of Birth :

Relation :

Occupation :

Name :

Date of Birth :

Relation :

Occupation :

Name :

Date of Birth :

Relation :

Occupation :

Name :

Date of Birth :

Relation :

Occupation :

Other Information:-

Languages Known :
Strengths :

Weakness :

Hobbies

5
Professional References:-
(Please provide two references)

Name Designation Contact Number

I certify that the above information is correct and complete to the best of my knowledge and belief
and nothing has been concealed. If any time I am found to have concealed any information or given
false details, my appointment shall be liable to terminate without any notice or compensation.

Place:
Date: Signature

6
 Bank Account Details

BENEFICIARY NAME

BANK NAME

BRANCH ADDRESS

A/C NO.

IFSC CODE

BRANCH CODE

I hereby confirm that above mention details are correct.

Name: Date:
Place:

Signature
 SS KOTHARI MEHTA & CO.
DECLARATION CUM JOINING
REPORT

This is to declare that I am not working with any other Firm.

That I was previously working with from

to (copy of Relieving letter/ resignation acceptance
attached).

That I am a bonafide member of the Institute and a copy of my membership no and

latest receipt of membership is attached.

Signatures:
Name :
Date :
 (For Unexempted /Exempted Establishments) Employee code
Date of Joining
FORM 2 (Revised)

NOMINATION AND DECLARATION FORM

(Declaration and Nomination Form under the Employees’ Provident Funds and Employees’ Pension Scheme)
(Paragraphs 33 & 61 (1) of the Employees’ Provident Funds Scheme, 1952 and paragraph 18 of the Employees’ Pension Scheme, 1995)

1 Name (in Block Letters) :

2 Father’s/Husband’s Name :
3 Date of birth :
4 Sex :
5 Marital Status :
6 Account No. (PF/EPS Number) :
7 Address (Residential) : Permanent :

Temporary :

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 and Address of the nominee/ nominees Nominee’s Date of Total amount If the nominee is a
relationship Birth or share of minor, name and
with the accumulations relationship and
member in Provident address of the
Fund to be guardian who may
paid to each receive the amount
nominee (%) during the minority of
nominee
(1) (2) (3) (4) (5)

100%

1 * Certified that I have no family as defined in para 2(g) of the Employees’ Provident Funds 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.
3. * Strike out whichever is not applicable.

----------------------------------------------------------------------
Signature or thumb impression of the subscriber
Note: - A Fresh nomination shall be made by the member on his marriage and any nomination made before such marriage
shall be deemed to be invalid

# If Married –> Spouse, Children (married or unmarried), his/ her dependent parents, deceased son’s w idow and children.
If unmarried then Parents, Brother, Sister or any other person(s).
Page No. – 1
 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.

Sl.No. Name and address of the family members Date of Birth Relationship with
the member

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

1
2
3
4
** 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 persons for receiving the monthly widow pension (admissible under para 16 2(a) (i) and (ii)
of Employees’ Pension Scheme, 1995 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)

Dated the :
………………………………………
Signature or thumb impression
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./Kumari_ employed in my establishment
after he/she has read the entries/the entries have been read over to him/her by me and got confirmed by him/her.

Place: __
Dated the
………………………………………………………….
Signature of the Employer or other authorised
Officer of the establishment
Designation……………………………………….
Name and address of the Factory/Establishment
or rubber stamp thereof
$ - Applicable if Married -> To Spouse and Children (include children adopted legally before death in service.

$$ - Applicable to both Married and unmarried – (1) Married ----- To any person(s) other than spouse and children.
(2) Unmarried -------- To Parents, Brother, Sister or any other person(s).

Page No. - 2
 New Form No.11- Declaration Form
(To be retained by the employer for future reference)

EMPLOYEES PROVIDENT FUND ORGANIZATION Emp Code:

Employees provident funds scheme, 1952 (paragraph 34 & 57) &
Employees pension scheme 1995 (paragraph 24)
Company:

(Declaration by a person taking up employment in any establishment on which EPF Scheme, 1952 end /of EPS1995 is applicable)
1 Name of the member
2 Father’s Name ( ) Spouse’s Name ( )
(Please Tick Whichever Is Applicable)
3 Date of Birth (DD/MM/YYYY)
4 Gender: ( male / Female /Transgender )
5 Marital Status (married /Unmarried /widow/divorce)
6 (a) Email ID:
(b) Mobile No:
7* Whether earlier a member of Employees ‘provident Fund Scheme 1952 Yes  No 
8* Whether earlier a member of Employees ‘Pension Scheme ,1995 Yes  No 
If response to any or both of (7) & (8) above is yes. MANDATORY FILL UP THE (COLUMN 9)
a) Universal Account Number(UAN)
b) Previous PF a/c No AP HYD EST.CODE EXTN PF NO.
9 c) Date of exit from previous employment (DD/MM/YYY)
d) Scheme Certificate No (if Issued )
e) Pension Payment Order (PPO)No (if Issued)
a) International Worker: Yes  No 
b) If Yes , State Country Of Origin (India /Name of Other Country)
10
c) Passport No
d) Validity Of Passport (DD/MM/YYY) to(DD/MM/YYY)
KYC Details: (attach Self attested copies of following KYCs) **
a) Bank Account No .& IFS code
11
b) AADHAR Number (12 Digit)
c) Permanent Account Number (PAN),If available
UNDERTAKING
1) Certified that the Particulars are true to the best of my Knowledge
2) I authorize EPFO to use my Aadhar for verification / e KYC purpose for service delivery
3) Kindly transfer the funds and service details, if applicable if applicable, from the previous PF 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
4) In case of changes In above details the same Will be intimate to employer at the earliest
Date:
Place Signature of Member
DECLARATION BY PRESENT EMPLOYER
A) The member Mr./Ms./Mrs ………………..has joined on …………….and has been allotted PF Number……………………………….
B) In case 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 PF account number /UAN 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 (Form13) for transfer
of funds from his previous establishment.
Date
Signature of Employer With seal of Establishment
APPENDIX I: ANNUAL INDEPENDENCE CONFIRMATION

Objective: To obtain reasonable assurance that all partners and staff required to be independent by
the COE have complied with the firm’s policies and procedures on independence.

Yes / No
1. Have you any court judgement against you in the last ten years (excluding motoring
offences), been declared bankrupt or entered into a voluntary arrangement with your
creditors, been disqualified from being a director or acting in the management affairs of a
company?
2. Have you been investigated for professional misconduct, subject to disciplinary
procedures by a professional body, reprimanded, excluded, disciplined or publicly
criticised by a professional or regulatory body?

3. Do you or any members of your family (spouse or equivalent, dependents, parents, non-
dependent child or siblings) have a family or personal relationship with directors or
employees in positions of influence in the firm’s clients?

4. Do you or any member of your family (spouse or equivalent, dependents, parents, non-
dependent child or siblings) have a direct financial interest or material indirect financial
interest in any of the firm’s clients?

5. Do you or any member of your family (spouse or equivalent, dependents, parents, non-
dependent child or siblings) hold shares on trust for any of the firm’s clients?
6. Have you or any member of your family (spouse or equivalent, dependents, parents, non-
dependent child or siblings) received any financial support or any benefit from any of the
firm’s clients?
N.B.: This includes loans, grants and gifts of significant value of over CU……… and any
other financial support, either directly or indirectly.

7. Have you accepted goods or services on favourable terms or received undue hospitality
from a client?
8. Are you aware of any conflicts of interest that an engagement may create with any of the
firm’s existing clients?
9. Do you provide any services to any of the firm’s clients directly or indirectly through your
family (spouse or equivalent, dependents, parents, non-dependent child or siblings) or
other business associates?
10. Do you have any potential employment with, or have you been employed in the last two
years by any of the firm’s clients?
If the answer to any of the above questions is yes, or if you are aware of any other threats to your
independence, provide full details including the client names in the space below or as an
attachment.

I confirm that I and my family (spouse or equivalent, dependents, parents, non-dependent child or siblings)
have, except where noted above, complied with all requirements of the firm’s independence policies and
that the above details are correct to the best of my knowledge and based on the information I have to the
date of this declaration. I undertake to keep the firm fully informed of any changes, within a week of them
arising. I also acknowledge that I am fully aware that the firm has the right to take disciplinary and other
appropriate action if any of the declaration above turns out to be false.

Name: Signature: Date:

 Computer / Laptop Usage Policy

SS Kothari Mehta & Co has IT policy with respect to Desktop Computer / Laptop usage within its office /
premises and all users are requested to strictly abide by the same.

Desktop computer or laptop will be given to the user for the official usage, as per the profile of the
person. Most roaming users will get Laptop while Desktop computers will be provided to all non-roaming
users.

Software/programs will be installed as per the circulated SS Kothari Mehta & Co Software usage policy. If
user requires additional software to accomplish his / her work then the request for the same will have to
be sent to IT department, who will put up the request to the management for the necessary licenses
approval / procurement and inclusion of these softwares in SS Kothari Mehta & Co permissible software
usage list.

All facilities and resources like server space, printers, scanner, internet access, e-mail access, ERP client
access etc. will be provided considering his / her work profile in the company with duly approved by the
departmental head and IT together.

Users will be provided access to various servers and application to meet his/her working requirements
depending upon his / her work profile in the company. For server or software application access, he shall
be provided various users name and passwords by the IT department. Users are advised to change the
password of their user account at the time of his/her first login and keep it strictly confidential and should
not share the password with anyone. For any help or clarification, he / she should contact IT.

IT team, under the order of the management can seek the access of the desktop computer / laptop of the
users at any time without any prior information with respect to the following: necessary backups, for virus
checking, IT audit etc. Users are advised to extend their full support in this regard.

Users are advised to take proper care of their Laptop and other accessories provided to them. In case
physical damage/ loss/ stolen, the current value will be charged from the user concerned.

In case of resignation/ termination, Users are instructed to provide all the data in soft form to IT
Department and to the concerned Departmental Head. Also at the time of leaving, Users are instructed to
handover the physical laptop to the IT Department failing which the current value of the same will be
recovered from his/her full and final settlement.

Users are advised not to share any official data with any third party/ outside person. If any employee, at
any time, found guilty, Management is authorized to take legal action against the said employee.

Personal Computer Usage within SS Kothari Mehta & Co:-

No personal computer (Desktop / Laptop) will be allowed to be used in the office, no network access will
be provided to the user.

Personal computer (Desktop / Laptop) will be allowed to be used within the SS Kothari Mehta & Co office
premises or the network only after special approval from the management and IT Department in writing.

If anyone is allowed to use his / her personal computer (Desktop / Laptop), He or She shall have to abide
by all the SS Kothari Mehta & Co IT rules / policies circulated or announced time to time (described in the
sr. No. 1 to 5 listed above).
IT help will be provided for only those application / software supplied or provided by IT department for
official usage and those listed in the SS Kothari Mehta & Co permissible usage IT list.

No repairing or maintenance cost shall be borne by the company related with hardware and no
replacement cost for battery will be reimbursed for all such personal computers.

No support for Hardware malfunctioning will be provided to the user. User will have to get the same
repaired by himself.

No support for additional S/w (other than the usable software under SS Kothari Mehta & Co IT policy)
installed in the user’s computer will be provided. User will be solely responsible for the fix of such
software malfunctioning in his / her computer.

The personal computer being used within the SS Kothari Mehta & Co (IT network) will automatically come
under the governance of all the protocols of all SS Kothari Mehta & Co IT policies being followed within
the company and are released time to time.

Management will not be liable to bear any penalty charged by third party in case of any third party
software usage violation caught during their audit.

Signature of Employee

Name:

Designation:

Department:
Date:

The Head – HR

SS Kothari Mehta & Company

New Delhi

Dear Sir/Madam

I, , S/d/w/o , aged about ,

Employee, R/o , do hereby solemnly affirm and

sincerely state on oath as follows:

1. That I have been recruited in M/s SS Kothari Mehta & Co (Hereinafter referred to

as the “Company”/”SSKM”) as in branch at

(Location) with effect from .

2. That during my employment with the Company, I agree and undertake that I shall be governed by the
Service rules, regulations, employee benefits, policies & procedures of the company detailed on the ESS
portal. I undertake to familiarize myself with the HR manual and all amendments incorporated in the same
from time to time by logging on to the ESS portal through my login credentials provided to me on my
joining the company. The terms and conditions laid down in the HR manual and as amended/ updated from
time to time and published on the portal, shall be binding upon me.

3. That I shall apply myself diligently and faithfully to all duties & responsibilities that may be assigned to me
from time to time and will conform to such directions that shall be given to me by my superiors. I shall be
responsible for efficient, satisfactory and economic operation in the areas of responsibility that may be
assigned to me from time to time. It is the intention of the Company that every employee of the Company
takes upon himself / herself a certain degree of responsibility and is accountable for the work undertaken by
him / her.

4. In addition to my adherence to the Code of Conduct detailed in the ESS Portal of the Company, I shall
also abide and understand that I am hired in a position of trust and confidence and realize my accountability
towards protection of Company’s interest and matters relating to its business and shall:

(i). Maintain complete confidentiality and high level of integrity in all my actions performed on behalf of the
company.

(ii). Practice high level of professionalism in business etiquettes, selection of attire, choice of language in
conversation & documents and in overall conduct.

(iii). I will help in maintaining & enhancing the congenial, disciplined, participative and supportive work
environment created by the company that fosters team spirit and high performance standards.
5. I declare that the assurances, undertaking, etc., in regard to my education/qualification certificates, work
experience certificates, previous employer’s certificates and all other certificates, information, declarations
and undertakings are true and correct. I undertake that there are no claims, damages or legal actions of any
nature instituted against me by any institutions, authorities including previous employer/s. I further
undertake that no legal cases of any nature had been instituted against me in past or currently in progress
even in my personal capacity. If any of the information or undertaking in relation to above is found untrue,
the Company reserves the right to take appropriate disciplinary action including termination of services. I
further authorize the Company to do the background verification check either on its own or through any
external agency in regard to the information provided by me or on my credentials and I will abide by the
decision of the Company taken on the basis of the said check and will indemnify the Company from any
claims arising there from.

6. I declare that I shall not do any act that may cause loss/disrepute to any of my previous employer/s by
mis-using their data/information to my personal or official gains and I shall hold harmless and indemnify the
Company from all actions and proceedings if any, initiated by my previous employer/s or their clients or any
third party before any Forum/Court/Authority in this regard.

7. I agree and undertake that during the term of my appointment with the Company, I will not, directly or
indirectly solicit, induce, recruit, or encourage any Company employee/s, who were during the term of my
appointment, employees of the Company, to leave their employment, or take away such employees, either
for myself or for any other person or entity without the Company’s express written consent. I further agree
and undertake that I will not engage in soliciting business or allied business that is similar or competitive
with the business of the Company, with those clients with whom I had any contact, during my employment
and for a period of one (1) year after my employment ceases with the Company.

8. I agree and undertake that I will not indulge in any unethical acts or practice which is against the interests
of the Company and/or Clients/Colleagues and/or which are illegal and not in conformity with the policies
and practices of the Company and Statutory rules, regulations and Acts.

10. I agree and undertake that I will maintain and protect the confidentiality of the information received by
me while discharging my official responsibilities. I agree and undertake that I will not misuse or share the
information with anybody not eligible or connected to have this information either for my personal benefit
or otherwise and even undertake to keep the information confidential even after leaving the Company. In
this regard I will fully comply with the guidelines enunciated in my terms of appointment.

11. I agree and undertake that during my employment in the Company, I will not indulge in any sort of un-
authorized financial transactions in my official capacity within, as well outside the Company.

12. I agree and undertake to report/bring to notice, immediately to the reporting head or Company’s
competent authority, any fraud/deviations/manipulations etc., noticed by me in any offices of the Company
and further state that such information shall not be withheld by me knowingly or consciously.

13. I state that I have received and read the Data and Information Systems Protection Policy and Procedures
prescribed for use of information and system resources at SSKM and undertake to adhere to the same and
even undertake to keep the information confidential even after leaving the Company. The aforementioned
policy contains the Password Security, Logical Access Security, Network Security, Software Security, Physical
Security, E-mail Security, Internet Security, Remote Access Security, Privacy Issues, Intranet Security, Virus
Protection & Prevention and Desktop/Laptop Security and End User Computing. In case of any breach of the
practices and policies, I shall be liable to such action as deemed fit by the management of the company.
14. I agree and undertake that the Company reserves the right to decide whether any violations have been
committed by me in terms of this Undertaking and in regard to the terms of my appointment. Further I
agree and undertake that, in case the Company concludes that I have violated or breached any of the terms
of this undertaking or of my appointment, the Company can initiate appropriate legal as well as disciplinary
action which shall not be limited to Suspension, Termination, Recovery of financial loss,
Adjustment/Withholding of my payable dues. 15. I agree and undertake that I shall indemnify the Company
against any loss, damage, proceeding which the Company might suffer due to any wrongful, malafide acts,
negligence, gross dereliction of duties on your part. Such indemnity shall not prejudice the right of the
Company to terminate my services on such count or the right of the Company to seek other remedies which
the Company may have to make good the loss, damage, etc.

I have read the contents fully and understood the same and herewith undertake to abide in all its entirety.

Name:

Signature:

Place: