Puregen Healthcare Pvt Ltd Affix a Photo

here

EMPLOYMENT FORM
POST APPLIED FOR: __________________________________ Desired Location:________________________
P
NAME (IN BLOCK LETTERS): ___________________________________________________________________
E
R (First name) (Middle name) (Surname)
S
Gender (Tick the applicable): Male Female Marital Status: Married Single Divorced
O
N Date of Birth (DD/MM/YYYY):___________________ Date of Wedding (DD/MM/YYYY):_________________
A
L Mobile no.:___________________; Landline: _________________; Email: _____________________________

PRESENT ADDRESS FOR COMMUNICATION:

__________________________________________________________________________________________
I __________________________________________________________________________________________
N __________________________________________________________________________________________
F
O PERMANENT ADDRESS: (Tick the box if it’s the same as present address)
R
M
A
T
I SAVING BANK DETAILS: (Please provide account’s cancelled cheque leaf along with application)
O
Bank Name:_____________________________________ A/c no.:____________________________________
N
Bank Address:______________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

IFSC CODE: _______________________;

PAN no.:____________________________; Aadhar no.:_______________________________________

OLD PF no. if any with company name: _____________________________________________________

OLD ESIC no. if any with company name: ____________________________________________________

H
E Blood Group: ____; LAST MAJOR SURGERY / ILLNESS (If any): _________________________________
A
L ARE YOU SUFFERING FROM ANY OF THE FOLLOWING DISEASES? IF YES PLEASE TICK IN ( )
T
H AGE
Family Details NAME ADDRESS OCCUPATION
(Yrs)
&
FATHER
F        
A MOTHER
M        
IL SPOUSE
       
Y
CHILDREN 1
       
CHILDREN 2
I        
N
BROTHER 1
F        
O BROTHER 2
R        
M SISTER 1
A          
 
T SISTER 2
       
I
1. BLOOD PRESSURE ( ); 2. CHRONIC BRONCHITIS ( ); 3. AIDS ( ); 4. ASTHMA ( ); 5. AIDS ( );
O
6. DIABETES ( ); 7. VENEREAL DISEASES ( ); 8. SKIN DISEASES ( )
N

NAME OF THE YEAR ATTENDED

EDUCATION BOARD OR TOTAL
SCHOOL / MEDIUM MARKS (%)
LEVEL UNIVERSITY FROM TO MARKS
INSTITUTIONS
E SSC
D            
U HSC
           
C
GRADUATIO
A
N            
T POST
I GARDUATIO
O N            
N
OTHERS
           
Any other educational courses that you are currently pursuing? If yes, please share the details
D
E Course name:__________________; Name of the Institution:_________________________;
T Duration of course:_______________
A
IL Expected date of completion of this course:____________________________________
S
 Mode of course: Regular ( ); Part Time ( )

Academic achievements (ranks, merit, scholarship, prizes etc..) _______________________________

__________________________________________________________________________________________
__________________________________________________________________________________________

EXTRA CURRICULAR ACTIVITIES: _______________________________________________________________

__________________________________________________________________________________________
__________________________________________________________________________________________

PLEASE WRITE NA IF IT IS NOT APPLICABLE

W
START WITH RECENT EXPERIENCE, PLEASE SPECIFY CLEARLY IN CASE OF PART TIME/ CONTRACT WORK
O
R
EXPERIENCE
K LAST DRAWN
FULL TIME DESIGNATIO REASON OF
ORGANISATION PERIOD DURATION SALARY
N
PART TIME LEAVING PER MONTH
E
Start Date:
X
  Last Date:          
P
Start Date:
E
  Last Date:          
R
Start Date:
I
  Last Date:          
E
Start Date:
N
  Last Date:          
C
Start Date:
E
  Last Date:          

P
R Minimum 3 references must & must have at-least worked with them in the past.
O
F Known
E since how
NAME OF THE PERSON OCCUPATION EMAIL CONTACT NO.
S many
S years
I
O        
N
A        
L
R        
E
F        
E
       
R
E
N
C
E
S
NOMINATED PERSON TO BE CONTACTED IN CASE OF EMERGENCY:________________________________

NAME: ____________________________; RELATIONSHIP:_______________; CONTACT:__________________

ADDRESS:__________________________________________________________________________________
__________________________________________________________________________________________

LANGUAGE KNOWN OTHER THAN MOTHER TONGUE

CAN CAN CAN CAN

UNDERSTAND SPEAK READ WRITE
( ) ( ) ( ) ( )
( ) ( ) ( ) ( )
( ) ( ) ( ) ( )
( ) ( ) ( ) ( )

DO YOU HAVE ANY LEGAL OBLIGATIONS TO YOUR PREVIOUS EMPLOYER? YES ( ); NO ( )

If yes, please mention:_______________________________________________________________________

__________________________________________________________________________________________
__________________________________________________________________________________________

IF SELECTED, BY WHEN YOU CAN JOIN OUR ORGANIZATION: _____________________________________

DECLARATION
I CERTIFY THAT THE ABOVE STATED INFORMATIONIS TRUE TO THE BEST OF MY KNOWLEDGE & BELIEF. ALL
THE ACADEMIC MARKS/ PERCENTAGE/ YEARS ARE TRUE. I AGREE THAT IN CASE THE COMPANY FINDS AT ANY
TIME THAT THE INFORMATION GIVEN TO ME IN THIS FORM IS NOT CORRECT, THE COMPANY WILL HAVE
RIGHT TO WITHDRAW MY LETTER OF APPOINTMENT AT ANY TIME WITHOUT NOTICE OR COMPENSATION.

PLACE:

DATE: SIGNATURE OF THE CANDIDATE