BACKGROUND VERIFICATION FORM

FILL THIS FORM CLEARLY, CORRECTLY AND IN CAPITALS ONLY

Personal Information
Full Name (expand your surname)

Former Name / Maiden Name

(Applicable only for married females)

Father's Name

Date of Birth (DD/MM/YY)

Gender

Social Security Number (if applicable)

Nationality
Passport No.
Driving License No.
Female
PAN Card No.
Current Address
Period of
From (MM/YY)
To (MM/YY)
(Mention Full Address with Pincode & Landmark)
stay
Full Name:
C/o,S/o,D/o:
Door No:
Street:
City/District:
State:
Pincode:
Prominent Landmark

Marital Status

Male

Permanent Address
(Mention Full Address with Pincode & Landmark)
Full Name:
C/o,S/o,D/o:
Door No:
Street:
City/District:
State:
Pincode:
Prominent Landmark

Period of
stay

From (MM/YY)

To (MM/YY)

Residence Phone Number

Mobile number

Residence Phone Number

Mobile number

Address History (List most recent first) - Mention about all the addresses wherever you stayed in the last
Period of Stay
From (MM/YY)

Mention Full Address

with Landmarks

To (MM/YY)

last two years

Contact Number(s)

C/o,S/o,D/o:
Door No:
Street:
City/District:
State:
Pincode:
Landmarks:
C/o,S/o,D/o:
Door No:
Street:
City/District:
State:
Pincode:
Landmarks:
C/o,S/o,D/o:
Door No:
Street:
City/District:
State:
Pincode:
Landmarks:
C/o,S/o,D/o:
Door No:
Street:
City/District:
State:
Pincode:
Landmarks:

Education Qualification - Mention complete details of SSC & Highest Degree

Course / Qualification Name

College Name & Address

(All Fields are mandatory)

Dates Attended
From
To

SSC (10th Class)

MM/YY

MM/YY

Full Time
Part Time
Highest Qualification (Mention Degree)

MM/YY

MM/YY

Full Time
Part Time
College Contact Person: Name& Designation:

landline Num:

Official Email ID:

University / Board
Name & Address

ID /Roll No

Please tick mark the documents submitted for this qualification along with this form
Marksheet
Provisional Certificate
Degree Certificate

None

Employment History (All fields are Mandatory)

Note: Give descriptive information where ever necessary e.g. If the current/previous company is closed, do mention it under "Reasons for
Leaving". Employee Code/ ID is mandatory. Incase you dont have an EMP ID/No., mention the same under respective field.
Current Employer - Please attach a copy of your Offer letter, Pay Slips, Increment letters
Name of Current Employer
(Company Name)
Address of Current Employer

Board No./HR Dept No.

Employee Code/ID

Employment Period
From

Designation

Manager's Name

Department

Manager's Contact No

To

Manager's Email ID

Duties & Responsibilities

Can the check be done now?

Yes
No

Reasons for leaving

First Salary (Gross Per Month)

Is this Position
Permanent
Last Salary (Gross Per Month)
Temporary
Contractual
Please tick mark the documents submitted for this employment
Offer Letter
Experience Letter

Agency Details (if temporary or contractual), provide details

Relieving Letter

Pay Slips

None

Previous Employer 1 - Please attach a copy of your relieving letter or experience letter
Name of Previous Employer (1)
(Company Name)
Address of Employer

Board No./HR Dept No.

Employee Code/ID

Employment Period
From

Designation

Department

Manager's Name

Manager's Contact No

To

Manager's Email ID

Duties & Responsibilities

Reasons for leaving

First Salary (Gross Per Month)

Was this Position

Permanent
Last Salary (Gross Per Month)
Temporary
Contractual
Please tick mark the documents submitted for this employment
Offer Letter
Experience Letter

Agency Details (if temporary or contractual), provide details

Relieving Letter

Pay Slips

None

Previous Employer 2 - Please attach a copy of your relieving letter or experience letter
Name of Previous Employer (2)
(Company Name)
Address of Employer

Board No./HR Dept No.

Employee Code/ID

Employment Period
From

Designation

Manager's Name

Manager's Contact No

To

Manager's Email ID

Duties & Responsibilities

First Salary (Gross Per Month)

Was this Position

Permanent
Last Salary (Gross Per Month)
Temporary
Contractual
Please tick mark the documents submitted for this employment
Offer Letter
Experience Letter

Department

Reasons for leaving

Agency Details (if temporary or contractual), provide details

Relieving Letter

Pay Slips

None

Reference Details: Provide details of both professional and personal references

Professional Reference: To be filled if you are currently working or experienced
Name, Company & Designation:
Current Address:

Contact No:
How do you know this person?

Personal Reference: Mention about any one of your friends or family members
Name & Occupation:
Current Address:

Contact No:
How do you know this person?

Please mention about GAPS during Education and Employment - MANDATORY (If there were NO GAPS, just leave it blank)
From (MM/YY)

To
(MM/YY)

Reason for Gap:

Complete Address and Location during gap:

From (MM/YY)

To
(MM/YY)

Reason for Gap:

Complete Address and Location during gap:

From (MM/YY)

To
(MM/YY)

Reason for Gap:

Complete Address and Location during gap:

Declaration and Authorization

I hereby authorize Pvt. Ltd.(or a third party agent appointed by the Company) to contact any former employers as indicated above and carry out all
Background Checks not restricted to education and employment deemed appropriate through this selection procedure. I authorize former employers,
agencies, educational institutes etc. to release any information pertaining to my employment/education and I release them from any liability in doing so.

I confirm that the above information is correct to the best of my knowledge and I understand that any misrepresentation of information on this application form
may, in the event of my obtaining employment, result in action based on company policy.

Signature:

Full Name:

Date: