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 - director@bitmpune.com 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

EMAIL- sminamdar@yahoo.com Cell- 9822006297

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