Background Verification Form Employee Code PERSONAL DETAILS Name of Applicant : SAMEEKSHA JAIN Surname: JAIN Middle-PUKHRAJ First-SAMEEKSHA
Maiden Name : SAMEEKSHA JAIN Employee Location
Have you ever been known by another name?
YES
NO
If Yes, please write the other name: NO.
Place of Birth: AJMER Sex: FEMALE Fathers Name: PUKHRAJ JAIN Home Phone- O2974-210431
Date of Birth (dd/mm/yy): 02/04/1989 Nationality: INDIAN Passport No.G8827222 SSN No. (Mandatory for US address) Office Phone-02974-228044228048 Mobile: 09351895873
RESIDENTIAL ADDRESS Permanent Address: BANK COLONY, PLOT NO. 04, PARSHAV SIROHI DISTRICT City : ABUROAD Pin Code : 307026 State : RAJASTHAN Nearest Landmark : DR.VIKRANT SAKSENAS RESIDENCE Name of the contact person at the address :PUKHRAJ JAIN Relationship of contact person : FATHER Landline No.02974-210431 Nature Of Location: Rented/Owned/Others: PARENTAL Residing Since (Mandatory):BIRTH Mobile No.09351895873 Preferred time of the day for conducting the verification, if any : DAY TIME Residing Till ( Mandatory):PERMANENT
Current Address BANK COLONY, PLOT NO. 04,PARSHAV SIROHI DISTRICT
City : ABUROAD Pin : 307026
State : RAJASTHAN Nearest Landmark : DR. VIKRANT SAKSENAS RESIDENCE
Contact Person at the address : PUKHRAJ JAIN Relationship of contact person : FATHER Landline No.02974-210431 Nature Of Location: Rented/Owned/Others: PARENTAL Residing Since (Mandatory): BIRTH Mobile No.09351895873 Preferred time of the day for conducting the verification, if any : DAY TIME Residing Till ( Mandatory): PERMANENT
EDUCATION RECORD EDUCATION RECORD (Start with the latest/ highest qualification; please attach photocopies of the documents ) All fields are mandatory Name & Address of School/College /Institute Name & Address of University its affiliated Type of Degree/Dipl oma obtained. State F for fulltime and P for part-time within brackets 12TH COMMERCE FULL TIME ST.ANSELMS SCHOOL, ABUROAD CBSE, NEW DELHI 10TH FULL TIME 2004 APRIL Dates Attended Roll Number/Regis tration Number/Exam Seat number
From
To
HGI, ABUROAD
CBSE, NEW DELHI
2006 APRIL
2007 MARC H 2005 MARC H
ROLL NO1226930
ROLL N01123933
PROFESSIONAL EDUCATION RECORD PROFESSIONAL EDUCATION RECORD (Start with the latest/ highest qualification; please attach photocopies of the documents ) All fields are mandatory Name & Address of School/College/Insti tute (Mandatory) Name & Address of University its affiliated (Mandatory) Type of Degree/Dipl oma obtained. State F for fulltime and P for part-time within brackets PGDM- I.B. & MARKETING .FULL TIME. Dates Attended Roll Number/Regis tration Number/Exam Seat number
From
To
SRI BALAJI SOCIETY,BIIB, PUNE
AICTE AFFILIATED, WESTERN REGIONMAHARASHTRA GUJARAT UNIVERSITY
2010 JUNE
2012 MAY
ROLL NUMBERIB-108135
BKMIBA-HLBBA, AHMEDABAD
BBA FULL TIME
2007 JUNE
2010 APRIL
ENROLMENT NUMBER200710101189
EMPLOYMENT RECORD
If you are still employed in this organization, please fill in the date before which you would not like the verification to be initiated in the To column. If you are not sure or would like to intimate this date later, please write 'Still Employed'
Employer 1 Full Name
Employee ID
From (mm/yy)
To (mm/yy)
Address
Phone Number
City
State
Country
Postal Code
Job Title
Reason of Leaving
Designation Supervisor Name & Title
Final Salary (Annual CTC) HR Manager Name
Supervisor s Phone Number
HR Manager Phone Number
EMPLOYMENT RECORD Employer 2 Full Name Employee ID From (mm/yy) To (mm/yy)
Address
Phone Number
City
State
Country
Postal Code
Job Title Designation Supervisor Name & Title
Reason of Leaving Final Salary (Annual CTC) HR Manager Name
Supervisor s Phone Number
HR Manager Phone Number
EMPLOYMENT RECORD Employer 3 Full Name Employee ID From (mm/yy) To (mm/yy)
Address
Phone Number
City
State
Country
Postal Code
Job Title Designation
Reason of Leaving Final Salary (Annual CTC)
Supervisor Name & Title
HR Manager Name
Supervisor s Phone Number
HR Manager Phone Number
EMPLOYMENT RECORD Employer 4 Full Name Employee ID From (mm/yy) To (mm/yy)
Address
Phone Number
City
State
Country
Postal Code
Job Title Designation Supervisor Name & Title
Reason of Leaving Final Salary (Annual CTC) HR Manager Name
Supervisor s Phone Number
HR Manager Phone Number
EMPLOYMENT RECORD Employer 5 Full Name Employee ID From (mm/yy) To (mm/yy)
Address
Phone Number
City
State
Country
Postal Code
Job Title Designation
Reason of Leaving Final Salary (Annual CTC)
Supervisor Name & Title
HR Manager Name
Supervisor s Phone Number
HR Manager Phone Number
REFERENCE VERIFICATION REFERENCE VERIFICATION Note The reference provided should be currently employed or engaged in a professional activity.
**Please ensure that the contact numbers of the reference are active numbers and are reachable for verification
PROFESSIONAL REFERENCE (1) (1)Full name of the Reference (professional) Telephone # and email ID
email - [email protected] cell 9766644288 SEEMA SINGH ZOKARKAR
Organization Relationship with the candidate
SRI BALAJI SOCIETY, BITM -PUNE. DIRECTOR OF BITM PROFESSIONAL REFERENCE (2)
(1)Full name of the Reference (professional) Telephone # and email ID
SATISH M. INAMDAR
Organization Relationship with the candidate
SRI BALAJI SOCIETY, BIIB-PUNE DIRECTOR OF BIIB
Information Release Form
To Whom It May Concern: Please print
I_______________________________________________________________________ Last name First name Middle name I hereby authorize (Pipal Research subsidiary of CRISIL ) and/or or their authorized representatives and contractors to verify information presented on my employment application/resume and to procure an investigative report or consumer report for that purpose. I hereby grant authority for the bearer of this letter to access or be provided with full details
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of my previous employment record held by any company or business for whom I previously worked. This information should include the dates of employment; the nature of the position held, [details of my salary upon departure] and an appraisal of my performance, capabilities and character. In addition, please provide any other pertinent information requested by the individual presenting this authority. I hereby release from liability all persons or entities requesting or supplying such information. of my qualification/degree (copy of my certificates attached) information in respect to my character from the records maintained by local authorities
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Signature:
Date: dd / mm / yyyy
