INTERVIEW PERSONAL DETAIL FORM

S No Details Response

1 Your name Maragatham A

2 Contact number 7871735660

3 Gender Female

4 Nationality Indian

5 PAN Card Number EVDPA6711C

6 Aadhar Number 582496165066

7 Email ID [email protected]

Source of Hire (Please choose one of the below and add the relevant
8 details)
Consultant (if Yes), write the name of the
8(a) consultant.

8(b) Contacted by HR TA Team (Yes/No) Yes

8(c 1) Employee Reference (if Yes).

Name of Employee Who referred you

8(c 2) Employee ID of the referred person

Job Portal (if Yes). Write the
8(d) name of the website.
Social Media (if Yes).
Write the name of the social media such as
8(e) facebook/linked/whatapp/etc
9 Are you an ex-employee of Omega Healthcare?
If so, please mentioned the

Previous Emp. ID
 Previous Work Tenure with Omega

Declaration: -
I Maragatham A, hereby declare that the information furnished above is true, complete
and correct to the best of my knowledge and belief. I understand that in the event of my
information being found false or incorrect at any stage, my candidature / appointment
shall be liable to cancellation / termination without notice or any compensation in lieu
thereof.
Place: - Chennai
Date : -
Signature:
Maragatham A
 Omega Healthcare Management Services Pvt. Ltd.

BACKGROUND VERIFICATION FORM

Ref

Educational qualification: B.Sc-home science (NFSM&D)

Full Name- Maragatham A Female Marital Status: unmarried

Date of Birth: 30.01.2002 Nationality- Indian Father's name: Anandan
Employee No: Designation:

Place of joining: Chennai Date of Joining: 16.05.2025

Current Residential Address: No – 165, raja street,
kannigaipair (V&P), periyapalayam, Chennai-601 102

Period of stay at current address: 23 years

Telephone (Home):- Mobile: 9952546709

Email address: [email protected]

Permanent address: No – 165, raja street, kannigaipair

(V&P), periyapalayam, Chennai-601 102

Telephone: Mobile: 9952546709

(Important: Copy of Mark sheet and Degree certificate MUST be attached)

 College name Queen marry’s College

College Address

University Name and address -

From — To Graduated Program Student ID/ Enrolment No

2019-2022 B.Sc home science 1913391071013
(NFSM&D)

Type of degree : UG Graduation date Major Sub •ect

Nutrition & dietetics

Employment History — (Relieving letter copy to be attached till last but one employer)

Company Name: Annexmed Healthcare Position Held& Executive – Medical

coder-E/M op,
surgery
Telephone

Employment date: ( Date, Month , Year) From: Employee code:

13.10.2024

Whether employment is temporary or permanent in Nature Permanent

Agency details ( If temporary or Contractual)

Responsibilities: medical coding

Remuneration: Reason for leaving: To enhance

and
expertise
my current
skills with
the
upcoming
 projects and
in search of
new
opportunitie
s.
Reported to: name, Position & Contact

Ref: OMH-FOR-HRD-004-V1.O

Company Name: AGS HEALTHCARE Position Held& Dept Medical

coder,
multispecialit
y.
Address( Main office & Branch where worked) Telephone
Kosmo1, Ambattur

Employment date: ( Date, Month , Year) From: Employee code:

Oct 2022 – oct 2024

Whether employment is temporary or permanent in Nature Permanent

Agency details ( If temporary or Contractual)

Responsibilities: medical coding

Remuneration: Reason for leaving: To gain experience in

the existing fields
related to medical
coding
Reported to: name, Position & Contact

Can reference check be done: -

Name and contact details of 2 referees

Ref : OMH-FOR-HRD-004-V1.O
 Letter of Authorization

To Whomsoever it may Concern

I Maragatham A hereby Authorize Omega Healthcare Management Services Pvt Ltd and its authorized
representatives to verify information provided in my resume and application of employment, and to
conduct enquiries as may be necessary, at the company’s discretion. I authorize all persons who may
have all information relevant to this enquiry to disclose it to Omega Healthcare Management Services
Pvt Ltd or its representative. I release all persons from liability on account of such disclosure.

I Hereby authorize concerned authorities to dispatch my confidential report to Omega Healthcare

Management Services Pvt Ltd or its authorized representative.

Signed :

Name : Maragatham A

Date :
** As is the procedure followed by most police departments across India for criminal back ground
verification, It is possible that Police authorities may contact or visit the stated residence and at times
even ask to be physically present at the concerned Police station. It is part of the standard verification
Procedure.

UNDERTAKING NON-DUAL EMPLOYMENT

I,_____________ hereby declare that I will be under FULL TIME employment through WORK FROM
HOME MODEL with Omega Healthcare Management Services Private Limited. I __________________
also undertake and Acknowledge that I will not be employed either in part time or full time with any
other
Organization during my employment tenure with Omega Healthcare Management Services Private
Limited.

Upon breach of this undertaking my employment with the company shall be terminated immediately
without any prior notice.

I understand and undertake that the Company shall initiate appropriate legal action against me for any
loss caused to the company either direct or indirect resulting due to my acts breaching this undertaking.

Read and understood above and I accord my consent and willingness.

Signature : _____________________________
Name :

Date :

Letter of Undertaking - WFH

Self-Declaration – System Configuration & Conducive Infrastructure

I _______________undertake that I have sufficient space at my place of stay to accommodate

and keep systems allotted by the company, and I shall not claim for any additional remuneration
towards same

I_____________ also understand and undertake that I have obtained internet Broad Band
services with good connectivity speed at my cost and same shall be used as connectivity for
work production, in addition to same I also have power backup and I shall not claim for any sort
of reimbursement towards claim of internet broadband and power back.

Name of the Candidate:

Date:

Signature of the Candidate:

Self-Declaration - Acknowledgement form

Transportation Policy:

In Lieu with the offer extended from “Omega Healthcare Management Services Pvt Ltd” for the role
“medical coder”, I _____________ hereby acknowledge & accept that I have been informed on the
below mentioned transportation clauses before my DOJ,_______________(DD/MM/YYYY).

1. Considering the current Covid19 pandemic situation, I understand that company has enabled
WORK FROM HOME facility and I DON’T require any cab/Transportation Facilities until the
lockdown is lifted.
2. If the situation comes back to normalcy and if I’m required to report and work from office,
below mentioned shall be applicable and I am informed about the same
• Rs.750 (As per current policy) would be deducted from my salary pay in case I opt for company
transport
• That transportation for night shift employees (5:30PM to 2:30PM – As per the current policy) is
MANDATORY for Women employees & OPTIONAL for MALE Employees.
• That transportation for Night shift employees (5:30PM to 2:30PM – As per the current policy) is
both to & fro, and I am also aware that Pickup would be at common point and drop would be at
door step.
• That I would be eligible for CAB only if I work in Night shift (5:30PM to 2:30PM – As per the
current policy)
• I understand if I plan to shift my residence after joining Omega, I will confirm the availability of
cab from the Admin team before shifting my residence
3. My current residential address:

4. That transportation for night shift employees are provided within boundaries as explained at the
time of interview. The same will be confirmed by the Admin team if it falls within the boundary
limits at the time of providing transport when reporting into office premises
 5. I’m also aware that If my address falls outside the Boundary limits according to the transport
policies of Omega Healthcare Management Services PVT LTD, I will change my residential
location/address within the boundary limits, failing to do will result in termination of services

I________ hereby declare that I understood the transportation policy of Omega, and will be lonely held
responsible in case of any deviations.

Work from Office

Congratulation on your offer!!! And Welcome to Omega family.

As part of salary discussion, you had agreed to be available to work from office starting last
week of __________(joining date)and you do not have any objection on this matter.
Please confirm the same for us to formally on board you on rolls of Omega.

Name of the Candidate:___________________

Date:

Signature of the Candidate:

 Omega Healthcare Management Services Pvt Ltd
Background Verification – Pre-Screening Report by Internal TA team

Candidate Name Candidate Reference No

(As per Aadhar/KYC) (From Hiring Tool)

Offered Designation Joining Department

Location Expected Date of Joining

Summary of the verification done by Recruiter
SL. Status / Comments by
Verification Details
No Recruiter
1 10th Mark Sheet Verified
2 Academic Credentials 12th Mark Sheet Verified
(To be submitted in line with
resume) Degree / Diploma Certificates (as
3 Verified
applicable)
Aadhar Card - Self ID proof
4 Verified
Self ID Proof – Aadhar (Mandatory)
& PAN Acknowledgement copy
5 PAN card OR PAN Acknowledgment
submitted
Previous Employment Relieving letter / Resignation
6 Not Applicable
(Applicable to lateral Hires Acceptance Letter/Mail
7 only) Payslips / Last drawn Comp details Not Applicable
8 Resume (to be collected) Collected
9 Minimum Age Verified
10 SAM check Completed – Green
Other Verifications
11 OIG check Completed – Green
Professional Check –
12 Completed – Green
Employer/Education Institution
Personal Information declaration, No
Self-declaration Forms (if
13 Dual employment, consent for BG Completed
any)
Check etc

Final Comments by Recruiter: Verified – Good to Hire

Report Status: Green / Amber / Red

Recruiter Name Signature Date