Staff Screening Verification Form
PERSONAL INFORMATION
Applicant ID Bank ID Location Date of Joining
As indicated in your birth certificate/Passport/ID document, please provide details of your legal name:
Surname / Family name
First name (Given name)
Middle Name(s)
Alias/Nickname
Father’s Name
Mother’s Maiden Name
Have you ever been known by another name?
Former name, including family /maiden name
Date of Change
Date of Birth Country of birth Gender
IDENTITY DOCUMENT DETAILS
Please provide details of all ID documents (ID Cards, Passports, Certificates of Identity, etc.) held by you.
Identification Type
Identity Number
Country of Issue
Do you posses a US Social Security Number? Security Number
Do you posses a Canadian Social Insurance Number? Insurance Number
Primary Nationality / Citizenship
Secondary Nationality / Citizenship
CONTACT DETAILS
For phone numbers, enter country code, area code, telephone number & extension (if applicable)
Please select one primary contact (Home / Mobile / Office)
Home Tel. Mobile Tel.
Contact Email Office Tel.
RESIDENTIAL HISTORY
Starting with your current address & in descending date order, list all of your previous residential addresses over
the past five years.
Date From
Current Street Address / Town/ City/ District (mm/yyyy)
/ State/ County/ Province / Zip / Post code Date to
(mm/yyyy)
Date From
Permanent Street Address / Town/ City/ District (mm/yyyy)
/ State/ County/ Province / Zip / Post code Date to
(mm/yyyy)
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Staff Screening Verification Form
RESIDENTIAL HISTORY
Starting with your current address & in descending date order, list all of your previous residential addresses over
the past five years.
Date From
Current Street Address / Town/ City/ District (mm/yyyy)
/ State/ County/ Province / Zip / Post code Date to
(mm/yyyy)
Date From
Permanent Street Address / Town/ City/ District (mm/yyyy)
/ State/ County/ Province / Zip / Post code Date to
(mm/yyyy)
EDUCATIONAL QUALIFICATIONS
Starting with your highest academic qualification (e.g. BA, BSc, MA, MSc, PhD, etc.) and in descending order, please provide
details of all academic qualifications attained
University Name
Institution Address & Contact details
ID / Roll No.
Year Attended From & To
Major Subjects
Qualification gained
Full Time / Part time/ Correspondence
/ Distance Education
Have you graduated from this Institution?
OTHER QUALIFICATION
Year Attended
Institution Name ID / Roll No. Qualification gained
From & To
PROFESSIONAL QUALIFICATIONS
Please list any special or significant training, current membership of professional bodies or professional
qualification(s) (e.g. CPA, CFA) or licenses (e.g. NASD, FSA, MAS, AI, IR)
Qualification / Licence
Institution Name
Membership Number
Dates From Dates To
Year Qualification/ Licence Awarded
Principal Office Address
Institution Contact Number
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Staff Screening Verification Form
PROFESSIONAL EXPERIENCE
Starting with your current or most recent employer, list details of all employment over the last five years.
Current Employer's Name
May we seek verification of this employment now?
If "No", after what date can we contact
this employer?
Were you on Contract terms through an
employment agency?
Name of the Agency Employment Agency
Principle Office Address
Employment Agency Contact Person
Employment Agency Contact Number E-mail
Employer's Contact Details
HR Contact Person
HR Contact Phone Number E-mail
Employee Reference or Identification Number
Position / Job Title / Designation
Dates Employed (From) Dates Employed (To)
Department/Branch
Supervisor Name
Supervisor Title
Supervisor Contact Number & email E-mail
Last Gross Monthly Salary (State Currency)
Last Bonus
Other Remuneration / Compensation
Reason for Leaving
If any other reason please specify
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Staff Screening Verification Form
PROFESSIONAL EXPERIENCE
Starting with your current or most recent employer, list details of all employment over the last five years.
Employer's Name
Were you on Contract terms through
an employment agency?
Name of the Agency Employment Agency
Principle Office Address
Employment Agency Contact Person
Employment Agency Contact Number E-mail
Employer's Contact Details
HR Contact Person
HR Contact Phone Number E-mail
Employee Reference or Identification Number
Position / Job Title / Designation
Dates Employed (From) Dates Employed (To)
Department/Branch
Supervisor Name
Supervisor Title
Supervisor Contact Number E-mail
Last Gross Monthly Salary (State Currency)
Last Bonus
Other Remuneration / Compensation
Reason for Leaving
If any other reason please specify
EMPLOYMENT GAPS
Please account for all gaps in employment (exceeding 2 months) during the last five years.
Dates To
Reason for Gap
Dates From
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Staff Screening Verification Form
SELF CERTIFICATION LETTER
I _________________________________________________________hereby confirm and declare:
I. That the information which I have provided to Scope International Pvt. Ltd. in my [CV or application form] and
generally in connection with my application for the position of ________________________________ at Scope
International Pvt. Ltd., is true and accurate.
ii. That I do not have any previous criminal convictions for fraud, any form of financial wrongdoing or
misdemeanour or any other offence. I understand that minor non‐imprisonment offences like road traffic
offences are excluded from such convictions.
iii. That I am not subject to any current criminal proceedings.
iv. That I have not been adjudicated bankrupt and I do not have any financial judgments against me in the civil
courts for unpaid debts.
v. That I am not aware of any proceedings that have begun, or anybody's intention to begin proceedings, against
me for a judgment debt or which may result in a judgment debt.
vi. That the details I have provided in relation to my identity address, employment history and qualifications are true
and accurate.
vii. That I have the legal right to reside and work in India.
1. Please state any names, other than your legal name shown above, that you are commonly known by. If none,
please write “None”.
Name(s) Commonly Known By:
2. Please complete the relevant boxes below with the required details of any previous names. If none, please select
the relevant box.
Previous Name(s) Reason for Name Change(s) Date of Name Change(s)
D D / M M / Y Y Y Y
D D / M M / Y Y Y Y
D D / M M / Y Y Y Y
I confirm that I have no previous names
Please note that you may be required to provide supporting documentation in connection with any of the above
declarations.
I understand and agree that if any of the above statements prove to be false, Scope International Pvt. Ltd. may,
in its entire discretion, terminate my employment summarily without any notice or any payment in lieu of notice
and that such action by the Scope International Pvt. Ltd. will be made without any further compensation or legal
liability towards me.
I further understand that the Employment Verification with my current employer will be initiated at least 14 days
prior to my date of joining and I hereby give my consent in doing so.
Signed: [ ____________________________________________ ]
Date:
In the presence of:
Witness's Signature:
Witness's Full Name:
Witness's Occupation:
Witness's Full Permanent Address:
