BACKGROUND CHECK FORM
Please fill in the details with utmost attention, as these shall be verified by the Company and/ or by its
authorized representatives. Please Affix Your
Passport Size
Photograph
All details are compulsory.
PERSONAL DETAILS
Name of Applicant: Surname Middle First
Date of Birth (dd/mm/yy): Place of Birth:
Sex: Nationality:
Father’s Name: Passport No.:
Home Phone: Office Phone: Mobile:
RESIDENTIAL ADDRESSES
PERMANENT ADDRESS:
City: State: Pin Code: Phone No.:
Duration of Stay: From (mm/yy) To (mm/yy)
Nature of location: Rented Own Other (Specify)
CURRENT ADDRESS:
City: State: Pin Code: Phone No.:
Duration of Stay: From (mm/yy) To (mm/yy)
Nature of location: Rented Own Other (Specify)
All details are compulsory Strictly Private & Confidential
EDUCATION DETAILS
NAME & ADDRESS DATES ATTENDED
NAME & OF
COURSE MARKS (%) ROLL NUMBER/
ADDRESS OF BOARD / UNIVERSITY YEAR
ATTENDED CGPA REGISTRATION
QUALIFICATION SCHOOL / TO WHICH THE OF YEAR
(MORNING/ EVENING/ & NUMBER/ EXAM
COLLEGE/ SCHOOL / COLLEGE / CORRESPONDENCE) ENROL PASSED
CLASS SEAT NUMBER
INSTITUTE INSTITUTE MENT (MM/YY)
IS AFFILIATED TO (MM/YY)
10TH
12TH
GRADUATION
DEGREE:
DISCIPLINE:
Full Time
Part time
Distance
learning
course
POST
GRADUATION
DEGREE:
DISCIPLINE:
Full Time
Part time
Distance
learning course
ANY OTHER
DIPLOMA 1
ANY OTHER
DIPLOMA 2
All details are compulsory Strictly Private & Confidential
EMPLOYMENT RECORD: Starting with your present or most recent employer, please list last 2 employments. When listing consulting or
temporary assignments, under “Employer”, state the name of the consulting or temporary agency that placed you at the client site. Complete and
accurate dates (month/year) must be provided.
EMPLOYER 1 (Current): Employee Id: From (mm/yy): To (mm/yy):
Street Address: Employer’s Remuneration/Salary:
Phone No.:
City: State: Country: Postal Code:
Job Title: Reason for leaving:
Employment Status: (Please check the relevant box) Supervisor’s Details:
Name:
Full Time
Contract /Through Outsourcing Agency Title:
Phone No.:
Outsourcing Agency Details: E-mail id:
Name: (Preferably official)
Address:
HR Manager’s Details:
Tel No.: Name:
Description of Duties: Phone No.:
E-mail id:
(Preferably official)
Current Employment Authority Provided
Yes/No
If No When
EMPLOYER 2: Employee Id: From (mm/yy): To (mm/yy):
(Previous)
Street Address: Employer’s Remuneration/Salary:
Phone No.:
City: State: Country: Postal Code:
Job Title: Reason for leaving:
Employment Status: (Please check the relevant box) Supervisor’s Details:
Name:
Full Time
Contract /Through Outsourcing Agency Title:
Phone No.:
Outsourcing Agency Details: E-mail id:
Name: (Preferably official)
Address:
HR Manager’s Details:
Tel No.: Name:
Description of Duties: Phone No.:
E-mail id:
(Preferably official)
All details are compulsory Strictly Private & Confidential
EMPLOYER 3: Employee Id: From (mm/yy): To (mm/yy):
(Previous)
Street Address: Employer’s Remuneration/Salary:
Phone No.:
City: State: Country: Postal Code:
Job Title: Reason for leaving:
Employment Status: (Please check the relevant box) Supervisor’s Details:
Name:
Full Time
Contract /Through Outsourcing Agency Title:
Phone No.:
Outsourcing Agency Details: E-mail id:
Name: (Preferably official)
Address:
HR Manager’s Details:
Tel No.: Name:
Description of Duties: Phone No.:
E-mail id:
(Preferably official)
EMPLOYER 4: Employee Id: From (mm/yy): To (mm/yy):
(Previous)
Street Address: Employer’s Remuneration/Salary:
Phone No.:
City: State: Country: Postal Code:
Job Title: Reason for leaving:
Employment Status: (Please check the relevant box) Supervisor’s Details:
Name:
Full Time
Contract /Through Outsourcing Agency Title:
Phone No.:
Outsourcing Agency Details: E-mail id:
Name: (Preferably official)
Address:
HR Manager’s Details:
Tel No.: Name:
Description of Duties: Phone No.:
E-mail id:
(Preferably official)
All details are compulsory Strictly Private & Confidential
Personal References
Name Contact No. Company Designation Relationship with the
referee
1.
2.
DECLARATION & AUTHORIZATION
o I certify that the statements made in this application are valid and complete to the best of my knowledge. I
understand that false or misleading information may result in termination of employment.
o If upon investigations, any of this information is found to be incomplete or inaccurate, I understand that I will be
subject to dismissal at any time during my employment.
o I hereby authorize the Company and/or any of its subsidiaries or affiliates and any persons or organizations acting
on its behalf (TP --------------------------.), to verify the information presented on this application form and to procure
an investigative report or consumer report for that purpose.
o I hereby grant authority for the bearer of this letter to access or be provided with full details of my previous records.
In addition, please provide any other pertinent information requested by the individual presenting this authority.
o I hereby release from liability all persons or entities requesting or supplying such information.
o I authorize the Company to contact my present employer. Yes No
o I have read, understand, and by my signature consent to these statements.
SIGNATURE:
DATE:
NAME (IN BLOCK LETTERS):
DOCUMENTS REQUIRED (COMPULSORY) ATTACHED YES / NO
Completed & Signed Application Form
Copy of Relevant Education Certificates
One Passport Size Photograph
Current Address Proof (if stay at current
address > 6 months) else Longest Stay Address
Proof.
Please note: Your name should be mentioned on
the address proof.
Accepted address proofs: MTNL Bill / Electricity
Bill/ Copy of Rent Agreement/ Passport/ Voter Id/
Driving License.
Copy of all past Employment Appointment &
Relieving Letters / Salary Slips with employee
code
All details are compulsory Strictly Private & Confidential
