Background Screening Form

*All fields are mandatory

Personal Details
First Name Middle Name Last Name
KUMARI VASHNAVI
Applicant’s full
Name

Applicant’s Former
Name / Maiden
Name (If applicable)
PRATYUSH KUMAR
Father’s Name

NITU KUMARI
Mother’s Name

HOLDING NO-893,ZONE NO-1B,BIRSANAGAR,TELCO,JAMSHEPUR

Current Address

Contact no: 6203657326

Period of Stay From 1980 To PRESENT

Permanent Address HOLDING NO-893,ZONE NO-1B,BIRSANAGAR,TELCO,JAMSHEPUR

Contact no: 6203657326

Period of Stay From 1980 To PRESENT

Contact Details Landline No: NULL Mobile No: 6203657326

Email id: vashnavikumari12@gmail.com

Date of Birth: Gender: Marital Status: Nationality:
(MM / DD / YY) Female  Single  Indian
12/17/1997

Place of Birth:

Passport No: Permanent Account Driving License no:

No: (PAN)
BNJPV6505N NULL
Date & Place of
issue:
JAMSHEDPUR

Education details :

Graduation – 2021 KOHLAN UNIVERSITY 1 ST DEVISON

Higher Secondary – 2018 JAC 2ND DEVISION

 Secondary education – 2016 JAC 2ND DEVISION

Employment Details (Copy of Relieving/ Experience certificate & Salary slip is Mandatory)
(Please mention the employments, starting from the latest)

Previous Employer NO

Name of the Company: NULL

Address : NULL

Contact no:
Employee Code(*In case there is no Part Time/ Full Time:
Employee no, please state the reason) : Full Time

Period : (DD/ MM/ YY) Reporting Manager’s Name & Designation:

From:

To:
Contact No:

Last Designation held: Reason for Leaving:

Salary : (Please mention Gross/ Net/ CTC Name & Address of Agency if deputed:
per annum )

Fixed:

Variable: Employee code at the agency :

Is this employment linked with your current employment?

Yes 
(If yes, how)

No 

Professional Reference details (Please mention 2 references)

Name: Name:

Relation: Relation:

Mobile No: Mobile No:

Landline No: Landline No:

Email id: Email id:

Address: Address:
Designation & Company Name: Designation & Company Name:

I Ms.______kumari vashnavi________________________ _______ hereby authorize

_______________________________________________________________________or any
third party outsourced, hired and authorized by
________________________________________________________________________ to
verify all the above details mentioned.
I solemnly declare that all the information furnished above is true to the best of my
knowledge.

Name: KUMARI VASHNAVI Date:19/07/2021

Sign: Place:Jamshedpur