Background Verification Form

Employee Code Employee Location

PERSONAL DETAILS

Name of Applicant : SAMEEKSHA JAIN

Surname: JAIN
Middle-PUKHRAJ
First-SAMEEKSHA

Maiden Name : SAMEEKSHA JAIN

Have you ever been known by  YES  NO

another name?
If Yes, please write the other name:

NO.

Place of Birth: AJMER Date of Birth (dd/mm/yy): 02/04/1989

Sex: FEMALE Nationality: INDIAN

Father’s Name: Passport No.G8827222 SSN No.

PUKHRAJ JAIN (Mandatory for US address)

Home Phone- O2974-210431 Office Phone-02974-228044- Mobile: 09351895873

228048

RESIDENTIAL ADDRESS

Permanent Address: BANK COLONY, PLOT NO. 04, “PARSHAV”

SIROHI DISTRICT

City : ABUROAD State : RAJASTHAN

Pin Code : 307026 Nearest Landmark :

DR.VIKRANT SAKSENA’S RESIDENCE

Name of the contact person at the address :PUKHRAJ JAIN

Relationship of contact person : FATHER

Landline No.02974-210431 Mobile No.09351895873

Nature Of Location: Rented/Owned/Others: Preferred time of the day for conducting the
verification, if any : DAY TIME
PARENTAL

Residing Since (Mandatory):BIRTH Residing Till ( Mandatory):PERMANENT

Current Address
BANK COLONY, PLOT NO. 04,”PARSHAV”
SIROHI DISTRICT

City : ABUROAD State : RAJASTHAN

Pin : 307026 Nearest Landmark : DR. VIKRANT

SAKSENA’S RESIDENCE

Contact Person at the address : PUKHRAJ JAIN

Relationship of contact person : FATHER

Landline No.02974-210431 Mobile No.09351895873

Nature Of Location: Rented/Owned/Others: Preferred time of the day for conducting the
verification, if any : DAY TIME
PARENTAL

Residing Since (Mandatory): BIRTH 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 & Name & Address of Type of Dates Attended Roll

Address of University its affiliated Degree/Dipl Number/Regis
School/College oma tration
/Institute obtained. From To Number/Exam
State “F” Seat number
for fulltime
and “P” for
part-time
within
brackets

HGI, ABUROAD CBSE, NEW DELHI 12TH 2006 2007 ROLL NO-
COMMERCE 1226930
APRIL MARC
FULL TIME H

ST.ANSELM’S CBSE, NEW DELHI 10TH 2004 2005 ROLL N0-

SCHOOL, 1123933
FULL TIME APRIL MARC
ABUROAD H
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 Name & Address Type of Dates Attended Roll
School/College/Insti of University its Degree/Dipl Number/Regis
tute affiliated oma tration
obtained. From To Number/Exam
(Mandatory) (Mandatory)
State “F” Seat number
for fulltime
and “P” for
part-time
within
brackets

SRI BALAJI AICTE AFFILIATED, PGDM- I.B. & 2010 2012 ROLL
SOCIETY,BIIB, PUNE MARKETING JUNE NUMBER-
WESTERN MAY
.FULL TIME.
REGION- IB-108135
MAHARASHTRA

BKMIBA-HLBBA, GUJARAT BBA 2007 2010 ENROLMENT

UNIVERSITY NUMBER-
AHMEDABAD FULL TIME JUNE APRIL
200710101189

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 Employee From (mm/yy) To (mm/yy)

ID
Full Name

Address Phone Number

City State Country Postal Code

Job Title Reason of Leaving

Designation Final Salary (Annual CTC)

Supervisor Name & Title HR Manager Name

Supervisor ‘s Phone Number HR Manager Phone Number

EMPLOYMENT RECORD

Employer 2 Employee From To (mm/yy)

ID (mm/yy)
Full Name

Address Phone Number

City State Country Postal Code

Job Title Reason of Leaving

Designation Final Salary (Annual CTC)

Supervisor Name & Title HR Manager Name

Supervisor ‘s Phone Number HR Manager Phone Number

EMPLOYMENT RECORD

Employer 3 Employee From To (mm/yy)

ID (mm/yy)
Full Name

Address Phone Number

City State Country Postal Code

Job Title Reason of Leaving

Designation Final Salary (Annual CTC)

Supervisor Name & Title HR Manager Name

Supervisor ‘s Phone Number HR Manager Phone Number

EMPLOYMENT RECORD

Employer 4 Employee From To (mm/yy)

ID (mm/yy)
Full Name

Address Phone Number

City State Country Postal Code

Job Title Reason of Leaving

Designation Final Salary (Annual CTC)

Supervisor Name & Title HR Manager Name

Supervisor ‘s Phone Number HR Manager Phone Number

EMPLOYMENT RECORD

Employer 5 Employee From To (mm/yy)

ID (mm/yy)
Full Name

Address Phone Number

City State Country Postal Code

Job Title Reason of Leaving

Designation 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 SEEMA SINGH ZOKARKAR

(professional)

Telephone # and email ID email - director@bitmpune.com

cell 9766644288

Organization SRI BALAJI SOCIETY, BITM -PUNE.

Relationship with the candidate DIRECTOR OF BITM

PROFESSIONAL REFERENCE (2)

(1)Full name of the Reference SATISH M. INAMDAR

(professional)

Telephone # and email ID EMAIL- sminamdar@yahoo.com

Cell- 9822006297

Organization SRI BALAJI SOCIETY, BIIB-PUNE

Relationship with the candidate 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
n 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.
n of my qualification/degree (copy of my certificates attached)
n information in respect to my character from the records maintained by local authorities

Signature: Date: dd / mm / yyyy