FORM No 5A Date : 31-Jul-2023
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 10000228550.]
Code Number : TNMAS1861831000
1. Name of Establishment : Ganesan Suresh Kumar
2. Code Number of the Establishment under EPF Scheme : TNMAS1861831000
3. Postal address of the Establishment and its branches : No. 92/a11 And A12,, P V Rajamannar Salai, K K Nagar,
CHENNAI, TAMIL NADU - 600078 [Please see Annexure I]
4. Industry or business in which engaged : ESTABLISHMENT ENGAGED IN MANUFACTURE, MARKETING
SERVICING, USAGE OF COMPUTERS
5. Date of commencement of business : 01/01/2007
6. Date of closure by previous : N/A
7. Whether run by owner or lessee :
Run by Owner
8. Particulars of owners :
S. Name Date of Status Father's Name Residential Position
No. Birth Address Date
1 Mr. Ganesan Suresh 05/10/1970 Proprietor Muthiah Pillai 92/A11 and A12 PV 20/01/2007
Kumar Ganesan RAJAMANNAR SALAI
WEST KK NAGAR
Chennai Tamil Nadu
600078
9. In case on lease, particulars of lessee : N/A
S.No. Name Date of Birth Father's Name Residential Address Position
Date
10. If registered under Factories Act, particulars of Manager or : N/A
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. Ganesan Suresh 05/10/1970 Proprietor Muthiah Pillai 92/A11 and A12 PV 20/01/2007
Kumar Ganesan RAJAMANNAR SALAI
WEST KK NAGAR
Chennai Tamil Nadu
600078
Date: Signature of employer _____________________________
Application Number : 10000228550 Page 1 of 4
Code Number : TNMAS1861831000
Name of Employer _____________________________
Designation of Employer _____________________________
Seal of Establishment Mobile number _____________________________
Signature of employer at serial number of Owners details, if more than one employer.
Signature of remaining employers:
Signature Signature
Name _____________________________ Name _____________________________
Signature Signature
Name _____________________________ Name _____________________________
Signature Signature
Name _____________________________ Name _____________________________
Signature Signature
Name _____________________________ Name _____________________________
Application Number : 10000228550 Page 2 of 4
Code Number : TNMAS1861831000
ANNEXURE - I
Details of Branches of the Establishment
ANNEXURE - II
List of Branches having Separate/ Sub Code Number
Application Number : 10000228550 Page 3 of 4
Code Number : TNMAS1861831000
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 : Ganesan Suresh Kumar
Address of the Establishment : No. 92/a11 And A12,, P V Rajamannar Salai, K K Nagar, CHENNAI, TAMIL NADU - 600078
Code Number of the : TNMAS1861831000
STATUS OF THE SIGNATORY : # EMPLOYER / AUTHORISED SIGNATORY
# Strike whichever is not applicable
SPECIMEN SIGNATURE 1. _____________________________
2. _____________________________
3. _____________________________
SPECIAL INSTRUCTION, IF ANY _______________________________________________________
SPECIMEN SIGNATURE OF Mr/Ms _______________________________________________________ ATTESTED
Signature of employer _____________________________
Name of Employer _____________________________
Designation of Employer _____________________________
Seal of Establishment Mobile number _____________________________
[ ] Please tick if "Not Applicable" due to upload of digital signature
To be submitted separately for each Authorised Officer, if more than one.
Not to be submitted in this format if the employer after allotment of code number has uploaded digital signatures of the
Authorised signatories.
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.
Signature Not Verified
Date:2023/07/31 18:26:00 IST
Signed by:GANESAN SURESH KUMAR
Application Number : 10000228550 Page 4 of 4
Code Number : TNMAS1861831000
