Alembic Limited Please affix

4th Floor, Human Resource Management Division, Gorwa Road, Vadodara - 390 003
your passport
# 228 0550/ 228 0880. E-mail-hrd@alembic.co.in
size
photograph
over here
EMPLOYEE RELATED DATA :

1. Employee code : C.C. No.

2. Employee Name :
(Capital Letters)
First Middle Surname
3. Initial (Your Short Name ) :
4. Title : Mr. /Ms./Mrs./Dr./Major/Other, if any pl. specify 5. Gender : Male/Female
6. Father’s/Husband’s Name :
7. Category Designation :
8.
Present Address : Permanent Address :

Pin Code : Pin Code :

Present Tel No. (with STD code) : Permanent Tel No. (with STD code) :

9. Personal e-mail id :

10a. Birth Date : 10b. Joining Date :

DD MM YYYY DD MM YYYY
11. Personal Identification Mark :
12. Religion : 13. Caste :
14. Marital Status : 15. Marriage Date :
16. Name of Spouse :
17. Name of Spouse : 18. PAN No. (for I. Tax) :
(e.g. To Mention Gujarat as your state of Domicile, you should be living in the state for last 15 years).

EDUCATIONAL QUALIFICATION • (Beginning from the latest)

Education level : Please tick one (Post Doctoral, Ph. D. PG Degree, PG Diploma, Graduation, Diploma,
Undergraduate, H.S.C. Upto S.S.C.)

Name of Month &

Specialization University / College / Grade
Qualification Year of % Remarks*
subject Institute Class
(Degree / Dip.) Passing

* Please mention your exceptional academic achievement / s.

TRAINING UNDERTAKEN (Professional)

Training / Subject Title Duration Month / Year

Institute
(Days) (Date)

EMPLOYMENT HISTORY (Last employment first)

Organization Reporting To From To Last Gross

Designation Job Profile
Name & Address (Designation) mm/yy mm/yy Salary PA

Total Work Experience (Years) :

EMPLOYMENT HISTORY WITH ALEMBIC / ALEMBIC GROUP

Designation Salary At
Joining Joining Relieving Reason for At time time of
Company Dept.
Designation Date Date Leaving of leaving leaving
FAMILY INFORMATION :

Sr. Gender Birth Date** Blood Dependent

Name Relation Group
No. M/F (Y/N )

** Incase birthdate not know / not available, write age in years.

-- Whether any dependent Relative is Handicapped :

MISCELLANEOUS :

i) Languages Known :
Language Speak Read Write

ii) Passport Details :

Passport No. Date of Issue. :

Place of Issue : Valid upto :

iii) Hobbies :

iv) Proficiency in Sports :

Name of the Sports :

Details of type of Proficiency :

v) Special Talents & Skills :

Details of achievements if any

vi) Blood Group : Whether willing to donate blood : Yes / No

vii) Illness / Disease History :

Are you suffering from any major illness, please mention

IIIiness/Disease in the Past

OFFICIAL INFORMATION :

i) Extension Number :
ii) Internal e-mail id :
iii) Reporting to :

Designation :

iv) Housing details : Own / Rented / Company Provided :

If Company provided, Quarter No.

NOMINEE ENTRY INFORMATION :

Schemes Nominee Relation Address Proportion

Provident Fund

Employee
Pension Scheme

Gratuity

This is to certify that the above information provided by me is true to the best of my knowledge.

Signature of Employee