FORM No 5A Date : 14-Mar-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 2464966552.]
Code Number : MPIND0005615000
1. Name of Establishment : NAVALSINGH SAHAKARI SHAKKAR KARKHANA MARYADIT NAVALNAGAR
BURHANPUR MP
2. Code Number of the Establishment under EPF Scheme : MPIND0005615000
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3. Postal address of the Establishment and : BURHANPUR, null, BURHANPUR, BURHANPUR, MADHYA
its branches [Please see Annexure PRADESH - 450331
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4. Industry or business in which engaged : SUGAR
5. Date of commencement of business : 08/04/1981
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6. Date of closure by previous : N/A
7. Whether run by owner or lessee : Run by Owner
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8. Particulars of owners :
S. Name Date of Status Father's Name Residential Position
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No. Birth Address Date
1 Mr. MANOJ GUPTA 12/12/1968 IC SATISHCHANDRA NAVALNAGAR ZIRI 10/05/2023
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MANAGING GUPTA
DIRECTOR
9. In case on lease, particulars of lessee : N/A
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[Link]. 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. MANOJ GUPTA 12/12/1968 IC SATISHCHANDRA NAVALNAGAR ZIRI 10/05/2023
MANAGING GUPTA
DIRECTOR
Date:
Application Number : 2464966552 Page 1 of 3
Code Number : MPIND0005615000
ANNEXURE - I
Details of Branches of the Establishment
ANNEXURE - II
List of Branches having Separate/ Sub Code Number
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ANNEXURE - III
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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 SBIN0000342 STATE BANK OF INDIA BURHANPUR ot 10434282498 CURRENT YES
Copy of cheque of the primary account number : 10434282498
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Application Number : 2464966552 Page 2 of 3
Code Number : MPIND0005615000
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 : NAVALSINGH SAHAKARI SHAKKAR KARKHANA MARYADIT NAVALNAGAR
BURHANPUR MP
Address of the Establishment : BURHANPUR, null, BURHANPUR, BURHANPUR, MADHYA PRADESH - 450331
Code Number of the : MPIND0005615000
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 _____________________________
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Designation of Employer _____________________________
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 : 2464966552 Page 3 of 3
Code Number : MPIND0005615000
