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Archem Healthcare

REF. NO

Application Form

Kindly paste your
recent Passport
Size Photograph

Full Name
(In Block Letters)

_______________
First Name

________________

________________

Middle Name

Surname

(To be Filled by HR Department Only)
Interview for the Post of: ____________________________________
Source of Application: (Databank / Advt / Ref.) _________________
Division: __________________ Department: ____________________
Location: (HO / Factory / Field)________________________

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Religion: ___________________ Caste: ____________________ 7.: ________________________ Phone No.: _________________________ Mobile: Mobile: ________________________ _________________________ 8. Date of Birth: (DD) 2. Present Address: 7. Number _______________ 10. Do you have Passport? (Yes / No / Applied for) If yes. E-mail ID: ____________________________________________________________ 9.a. Marital Status: Single Married Divorced 5.) Remarks Father Mother Husband / Wife Brother / Sister Brother / Sister Child – 1 Child – 2 6. Family Background: Relationship Age Profession / Occupation Qualification Income (p. Gender: Male Female 4. Health: Have you or any of your family members suffered from any major illness / accident during the last five years? Yes / No 2 .PERSONAL DETAILS 1. Age: (MM) (YEAR) _____ Years ______ Months 3. Permanent Address __________________________________ ___________________________________ __________________________________ ___________________________________ __________________________________ ___________________________________ __________________________________ ___________________________________ Phone No.

Year) Read Write Mother Tongue: ___________ Others: _________________ __________________ 13. Language Speak Ended on Division / Percentage (Month .Year) 12. Academic Details: Duration Degree / Diploma Courses Name of Institute & Location Board / University Commenced From (Month .11. Work Experience: Total Years: ___________________ (Please Start with Current Company) Date Company’s Name & Location Designation From To Annual Salary Reason for leaving (CTC) 3 .

No. Two references: (other than your relatives) We will make such enquiries as it deems appropriate: Name: Address: Name: Address: Ph. No. (M) Ph. Etc. Describe your current Job Profile in brief: ________________________________ ______________________________________________________________________ ______________________________________________________________________ Whom do you report to? (Designation) _______________________________________ Who reports to you? (Designation) __________________________________________ 1. (M) I hereby declare that the above information is true to the best of my knowledge and I shall be solely responsible for any false information furnished by me. 15. Tax. Present Salary Details (Per Month): Salary per Month PF HRA LTA Bonus Other Benefits (Specify) Deduction (PF. Prof.) Salary in Hand Total Gross Salary (Per Month) Note: Please attach photocopy of your last salary slip / appointment letter.14. _______________________ (Date) _________________________ (Signature of Applicant) 4 .