Employees' Provident Fund Organisation
Form for allotment of Social Security Number (SSN)
PLEASE FILL IN CAPITAL ENGLISH LETTERS USING BLUE BLACK BALL POINT PEN ONLY AND LEAVE ONE BLANK BOX BETWEEN WORDS IN NAMES.
1. Current PF Account Number
Pension A c No. In case of
Exempted Establishment
MH 1783 A 29 should be written as
WB SLG 388 35 should be written as
2. Full Name of Subscriber (No initials and no titles. Expand initials. Do not abbreviate names.)
First Name
Middle Name(s)
Last Name
3. Father's Full Name (No initials and no titles. Expand initials. Do not abbreviate names. )
4. Mother's Full Maiden Name (No initials and no titles. Expand initials. Do not abbreviate names.)
First Name
Middle Name(s)
Last Name
First Name
Middle Name(s)
Last Name
5. Sex (Please darken the corresponding circle, as applicable) 6. Date of Birth
7. Place of Birth (no numerals please)
District
State Union Territory
Country
8. Nationality of Applicant (Please darken the corresponding circle, as applicable)
If other, please give name of the country of origin
9. Have you ever been known by any other name? (Please darken the corresponding circle, as applicable)
If yes, please give other name in full (Married ladies MUST give their maiden name here. No nick names)
First Name
Middle Name(s)
Last Name
Male Female

M H 1 7 8 3 A 2
W B S L G 3 8 8 3 5
9
Yes No
Indian Other
Village Town City
D D M M Y Y Y Y
Example :
(For office use only.Do not fill.)
EPFO Code D D M M Y Y Batch No. Sl. No.
SSN Form No.(For office use only)

57543
House Flat Door
Block No.
Area Locality
Taluka Sub-division
Road Street Lane
Post Office
Name of Premises
Building Village
Town City
District
State Union
Territory
Country
10. Correspondence Address
Pin Code
Town City
District
State Union
Territory
Country
11. Permanent Address Same as Correspondence Address
House Flat Door
Block No.
Name of Premises
Building Village
Road Street Lane
Post Office
Area Locality
Taluka Sub-division
Pin Code
(Please darken the circle, if applicable)
15. I hereby declare that above information is correct to the best of my
knowledge and belief.
(In block CAPITAL letters only)
13. Name as it would appear on
the SSN card (No nick name)
14. Father Name as it would
appear on the SSN card
(No nick name)
12. e-mail,if any
(Signature thumb impression of the subscriber without date)
TO BE FILLED ATTESTED BY EMPLOYER
16. Certified that the above declaration has been signed thumb impressed before me by ______________________________, 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. Also certified that the date of birth is as per employee records available with the establishment.
Signature of the employer or other authorised
officer of the establishment (box above)
17. Designation of Authorised Name of Establishment or rubber stamp thereof (box above)
Officer of the Establishment
18. Establishment Code
Date of Attestation
D D M M Y Y Y Y
Affix passport
size photograph
Date of Form
Validation
FOR OFFICE USE ONLY
Authorised Signatory 1
Place of Attestation

PF Account Number

Authorised Signatory 2
57543