FORM No 5A Date : 11-Jun-2024
EMPLOYEES' PROVIDENT FUND SCHEME 1952 (Please refer Para 36A)
EMPLOYEES' PENSION SCHEME 1995 (Please refer Para )
EMPLOYEES' DEPOSIT LINKED INSURANCE SCHEME1976 (Please refer Para
(Ist RETURN OF OWNERSHIP AFTER ONLINE APPLICATION FOR CODE NUMBER)
[THIS FORM 5A HAS BEEN GENERATED BY ONLINE FILLING/ UPDATION OF FORM 5A THROUGH ECR LOGIN
OF EMPLOYER. APPLICATION NUMBER IS 10000955603.]
Code Number : UKHLD2663454000
1. Name of Establishment : K.G.N. QUALITY ENTERPRISES
2. Code Number of the Establishment under EPF Scheme : UKHLD2663454000
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3. Postal address of the Establishment and : Ward No 01, Moh. Dilla Singh, Po Jaspur, Kashipur, UDHAM SINGH
its branches [Please see Annexure NAGAR, UTTARAKHAND - 244712
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4. Industry or business in which engaged : EXPERT SERVICES
5. Date of commencement of business : 11/08/2020
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6. Date of closure by previous : N/A
7. Whether run by owner or lessee : Run by Owner
8. Particulars of owners :
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S. Name Date of Status Father's Name Residential Position
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No. Birth Address Date
1 Mr. WAZID HUSAIN 24/11/1962 PROPRIET ABDUL RAZA WARD NO 01 DILLA 11/08/2020
OR SINGH, JASPUR
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KASHIPUR UDHAM
SINGH NAGAR
UTTARAKHAND 244712
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9. In case on lease, particulars of lessee : N/A
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S.No. Name Date of Birth Father's Name Residential Address Position
Date
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10. If registered under Factories Act, particulars of Manager or : N/A
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11. Particulars of persons mentioned above who are incharge and responsible for conduct of business of the
S. Name Date of Status Father's Name Residential Position
No. Birth Address Date
1 Mr. WAZID HUSAIN 24/11/1962 PROPRIET ABDUL RAZA WARD NO 01 DILLA 11/08/2020
OR SINGH, JASPUR
KASHIPUR UDHAM
SINGH NAGAR
UTTARAKHAND 244712
Application Number : 10000955603 Page 1 of 5
Code Number : UKHLD2663454000
Date:
ANNEXURE - I
Details of Branches of the Establishment
ANNEXURE - II
List of Branches having Separate/ Sub Code Number
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ANNEXURE - III
Details of Bank Account Number
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No. IFSC CODE BANK NAME BRANCH NAME ACCOUNT NO ACCOUNT TYPE PRIMARY
ACCOUNT
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1 HDFC000486 HDFC BANK JASPUR 50200051666801 CURRENT YES
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Copy of cheque of the primary account number : 50200051666801
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Application Number : 10000955603 Page 2 of 5
Code Number : UKHLD2663454000
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Application Number : 10000955603 Page 3 of 5
Code Number : UKHLD2663454000
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Application Number : 10000955603 Page 4 of 5
Code Number : UKHLD2663454000
SPECIMEN SIGNATURE CARD
To be submitted with all documents after the Code number is allotted through the online application.
FULL NAME OF THE AUTHORISED SIGNATORY __________________________________________________
Name of Establishment : K.G.N. QUALITY ENTERPRISES
Address of the Establishment : Ward No 01, Moh. Dilla Singh, Po Jaspur, Kashipur, UDHAM SINGH NAGAR,
UTTARAKHAND - 244712
Code Number of the : UKHLD2663454000
STATUS OF THE SIGNATORY : # EMPLOYER / AUTHORISED SIGNATORY
# Strike whichever is not applicable
SPECIMEN SIGNATURE 1. _____________________________
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2. _____________________________
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3. _____________________________
SPECIAL INSTRUCTION, IF ANY _______________________________________________________
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SPECIMEN SIGNATURE OF Mr/Ms _______________________________________________________ ATTESTED
Signature of employer _____________________________
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Name of Employer _____________________________
Designation of Employer _____________________________
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Seal of Establishment Mobile number _____________________________
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[ ] Please tick if "Not Applicable" due to upload of digital signature
To be submitted separately for each Authorised Officer, if more than one.
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Not to be submitted in this format if the employer after allotment of code number has uploaded digital signatures of the
Authorised signatories.
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In such case the letter generated from the portal after uploading the digital signature(s) to be sent.
In case of upload of digital signature, when page (6) specimen signature card is not applicable, strike this, but keep as
enclosure to the form 5A.
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Application Number : 10000955603 Page 5 of 5
Code Number : UKHLD2663454000
