BACKGROUND VERIFICATION FORM
Infosys employee number:
Candidate ID: 50045060
Infosys Limited
INSTRUCTIONS:
It is mandatory for you to complete the form in all respects
Please provide complete and correct information
BACKGROUND VERIFICATION FORM
Infosys Limited
Infosys Employee Code Location Date Of Joining
Pune 29-Apr-13
Candidate ID 50045060
Personal Information
Full Name (First, Middle, Former Name / Maiden Name
Last) (if Applicable)
Bhagwan Balkrishna Keskar
Father’s Name Nationality Date Of Birth Gender
Mr. Father Indian 09-Jul-81 Male
Social Security Number (if applicable):
Education Qualification (Highest Education)- Please attach copy of Degree and Final year mark sheet
College Name & Address University Name & Address Date attended Qualification ID/Roll
Gained
From To No
Please tick mark the documents submitted for this qualification along with this form
Marksheet Provisional Certificate Degree Certificate
Graduation details
College Name & Address University Name & Address Date attended Qualification ID/Roll
Gained
From To No
T.K.I.E.T Shivaji University 01-Jan-00 30-May-04 Part Time 4567
Please tick mark the documents submitted for this qualification along with this form
Marksheet Provisional Certificate Degree Certificate
Please account for any and all gaps of more than 3 months between last education and first
employment
From: To: Reason:
Complete Address and Location:
Previous Employment History (Inclusion of last 5 years of Employment or last two Employers
whichever is higher.) Please attach a copy of your relieving letter/service certificate
Note: Ensure that you are descriptive wherever necessary – e.g. If Co. is closed, do mention it. Employee Code/ ID/ Number is
mandatory. If your previous employer did not provide one, please mention and state reasons for the same.
Name of Employer(1): Address of Employer(1):
Suyash Labroratries Test
Telephone No: Employee Code/No: Designation: Department:
1234567898 1234 Production Supervisor IT
Employment Period: Manager’s Name: Manager’s Contact No:
Test 1234567898
From: To: Manager’s Email ID:
15-Jul-04 01-Feb-07
[email protected]Duties & Responsibilities: Reasons for leaving:
NA NA
Agency Details (if temporary or Was this Position:
contractual), provide details: Perm Full Time
NA
Please tick mark the documents submitted for this employment:
Service Certificate Relieving letter Offer letter None Any Other
Specify:___________________
Previous Employment History (Inclusion of last 5 years of Employment or last two Employers
whichever is higher.) Please attach a copy of your relieving letter/service certificate
Note: Ensure that you are descriptive wherever necessary – e.g. If Co. is closed, do mention it. Employee Code/ ID/ Number is
mandatory. If your previous employer did not provide one, please mention and state reasons for the same.
Name of Employer(2): Address of Employer(2):
Accelon Technologies Test
Telephone No: Employee Code/No: Designation: Department:
1234567898 23345 SAP Consultant IT
Employment Period: Manager’s Name: Manager’s Contact No:
Mr. Mgr 3456789098
From: To: Manager’s Email ID:
15-Feb-07 01-Apr-08
[email protected]Duties & Responsibilities: Reasons for leaving:
NA NA
Agency Details (if temporary or Was this Position:
contractual), provide details: Perm Full Time
NA
Please tick mark the documents submitted for this employment:
Service Certificate Relieving letter Offer letter None Any Other
Specify:___________________
Previous Employment History (Inclusion of last 5 years of Employment or last two Employers
whichever is higher.) Please attach a copy of your relieving letter/service certificate
Note: Ensure that you are descriptive wherever necessary – e.g. If Co. is closed, do mention it. Employee Code/ ID/ Number is
mandatory. If your previous employer did not provide one, please mention and state reasons for the same.
Name of Employer(3): Address of Employer(3):
Suzlon Energy Limited Add Line1
Telephone No: Employee Code/No: Designation: Department:
2345432345 1234 SAPOC PP executive IT
Employment Period: Manager’s Name: Manager’s Contact No:
Mr. Mgr 3456789098
From: To: Manager’s Email ID:
15-Apr-08 01-May-10
[email protected]Duties & Responsibilities: Reasons for leaving:
NA NA
Agency Details (if temporary or Was this Position:
contractual), provide details: Perm Full Time
NA
Please tick mark the documents submitted for this employment:
Service Certificate Relieving letter Offer letter None Any Other
Specify:___________________
Previous Employment History (Inclusion of last 5 years of Employment or last two Employers
whichever is higher.) Please attach a copy of your relieving letter/service certificate
Note: Ensure that you are descriptive wherever necessary – e.g. If Co. is closed, do mention it. Employee Code/ ID/ Number is
mandatory. If your previous employer did not provide one, please mention and state reasons for the same.
Name of Employer(4): Address of Employer(4):
Avartha Technologies Test
Telephone No: Employee Code/No: Designation: Department:
1234567898 34567 Functional Consultant IT
Employment Period: Manager’s Name: Manager’s Contact No:
Mgr 9876456789
From: To: Manager’s Email ID:
15-Jun-10 01-May-11
[email protected]Duties & Responsibilities: Reasons for leaving:
NA NA
Agency Details (if temporary or Was this Position:
contractual), provide details: Temp Part Time
NA
Please tick mark the documents submitted for this employment:
Service Certificate Relieving letter Offer letter None Any Other
Specify:___________________
Previous Employment History (Inclusion of last 5 years of Employment or last two Employers
whichever is higher.) Please attach a copy of your relieving letter/service certificate
Note: Ensure that you are descriptive wherever necessary – e.g. If Co. is closed, do mention it. Employee Code/ ID/ Number is
mandatory. If your previous employer did not provide one, please mention and state reasons for the same.
Name of Employer(5): Address of Employer(5):
IBM India Pvt. Ltd Add Line1
Telephone No: Employee Code/No: Designation: Department:
0923456789 34567 Application Consultant IT
Employment Period: Manager’s Name: Manager’s Contact No:
Mgr 9089897654
From: To: Manager’s Email ID:
15-Jun-11 24-Mar-13
[email protected]Duties & Responsibilities: Reasons for leaving:
NA NA
Agency Details (if temporary or Was this Position:
contractual), provide details: Perm Full Time
NA
Please tick mark the documents submitted for this employment:
Service Certificate Relieving letter Offer letter None Any Other
Specify:___________________
Please account for any and all employment gaps of more than 3 months:
From: To: Reason:
Complete Address and Location:
From: To: Reason:
Complete Address and Location:
From: To: Reason:
Complete Address and Location:
Documents Required
Education:
• Photocopy of degree certificate and all mark sheets or consolidated mark sheet including all
semesters/years.
For Bangalore University:
• A photo copy of both sides of Degree Certificate
• Copies of Marks sheet/Grade card for all years of attendance
• Name of college through which candidate has graduated
Employment:
• Photocopy of relieving / experience letter
Letter of Authorization
To whom it may concern
I hereby authorize Infosys Limited (“Infosys”) and any of its representatives (NASSCOM approved Agency) to verify
all the information provided in my application of employment and to conduct such enquiries as may be required by
Infosys Limited to verify facts of all such information provided by me. I hereby declare that this authorization shall
be valid till such time I remain an employee of Infosys.
I hereby authorize all Individuals, Private Establishments, Government Establishments/Agencies; Educational
Institutions who may have information relevant to this enquiry to co-operate and disclose to Infosys and/or its
representatives such information as may be required. I hereby release Infosys, all its personnel and representatives
from any liability which could result, either directly or indirectly, from the disclosure of information by a third party
to another party in response to such enquiries.
Signature:
Name in Block Capitals:
Date:
