DUA LIMA Retail Private Limited

EMPLOYMENT APPLICATION FORM

Position Applied For :

Please complete all the details mentioned in the form.

Please write NA wherever item is not applicable. Affix your recent
passport size
If you need more space for your answers, attach separate sheets. photograph
You may attach a resume' copy, but not as a substitute for this form.

PERSONAL DETAILS

Mr / Ms / Dr (Full name in block letters)

Last Name ________________________ Name ________________________ Father's / Husband's Name __________________

Name as per Aadhar Card: ________________________________________________

Gender: Date of Birth: Age : Years mnths

dd/mm/yyyy

Marital Status: No. of Children:

Date of Marriage :
dd/mm/yyyy
Present Address: Permanent Address:

PIN: PIN:

Phone Number: Phone Number:

Mobile No: E Mail ID:

Accomodation : Staying with Parents / Friends / Relatives

Nationality : State of Domicile: Religion

Languages Known : (Please underline your mother tongue)

Language Read Write Speak Understand

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FAMILY DETAILS :

Relationship Name Date of Birth Age Occupation Gender

Father

Mother

Brother/s

Sister/s

Spouse
(husband / wife)
Children (S-
Son/D- Daughter)

HEALTH :

Blood Group : Height : Cms Weight : Kgs

Do you wear spectacles / Lenses ? How do Power : L- R-

you rate your present health ? Good

Describe Briefly
Do you have any physical disability?
Yes / No
Have you met up any accident in the past ?
Yes / No
Any serious illness / operation ?
Yes / No

PERSON TO BE CONTACTED IN CASE OF EMERGENCY

Name Full Address Contact Nos.

GENERAL INFORMATION :

Date of Issue Date of Expiry

Personal IDs Place of Issue
dd/mm/yyyy dd/mm/yyyy

Passport No.

Aadhar Card Number

Pan Card No.

Do you own a car ? Two Wheeler ?

Have you ever been Prosecuted / Convicted? Is / was there any case pending against you in any court at any time ? If so, give
details.

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EDUCATIONAL / PROFESSIONAL QUALIFICATIONS :

Start Date End Date Branch of Marks /

Qualification Institute / Board / University Roll No.
dd/mm/yyyy dd/mm/yyyy Study Grade

Please specify in case of part time courses.

Explain breaks if any :

SHORT TERM COURSES / TRAINING PROGRAMMES ATTENDED :

Course
Course Institute / Location Year Certificate
Duration

CITATIONS / SCHOLARSHIP / AWARDS / PRIZES / OTHER HONOURS :

Nature of Award (Cash /

Name of Award Awarded by Institution / Association Year Granted
Book / Medal etc)

MEMBERSHIPS :

Profession Bodies :
Social Organizations :
Clubs / Societies :

EXTRA CIRRICULAR ACTIVITIES :

Interest in sports / games :

Hobbies :
Special interests :
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CAREER / EXPERIENCE PROFILE : Total work experience till date : Years

Are you presently employed ?

* Start with present job. * Mention outsourced agency name if on deputation. * Specify in case of temporary employment
Period of Employment
Salary at the time of
Name and Address of the Company with Telephone No. (dd/mm/yyyy)

From Date To Date Starting Leaving

Employee Code :

Employee Code :

Employee Code :

Employee Code :

Employee Code :

Employee Code :

Employee Code :

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…. Continued from Page 4

CAREER / EXPERIENCE PROFILE :

Total Experience
Your Designation Name, Designation, Contact No. of Reporting Official with the company Reasons for change
(In Months)

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Briefly outline your present job responsibilities :

Draw an organization chart to show who reports to you and to whom are you reporting to you in your present job:

Considering your qualification and experience, briefly describe why you should be selected for this position.

What are the values and beliefs that have guided your life so far and how do yoou see them influencing your future ?

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According to you what are your strengths and areas for improvement.

Strengths Areas For Improvement

REFERENCES :
(Name four persons other than relatives)
One reference : Your superior from past employment.
One reference : A person who had dealt with you in the course of employment / business.

Capacity in which he / she Feedback (For

Name Designation / Contact No. Period
knows you Office use only)

DECLARATION & AUTHORIZATION :

I confirm that the stated information is correct to the best of my knowledge and I understand that any misrepresentation of information in this application form

may, in the event of my obtaining employment, result in action based on Company policy.

I acknowledge and understand that my personal information is being collected by the company and this information will be used for internal and official purposes.
I hereby consent to the above.

I hereby also authorize the Company to contact any of my former employers as indicated above and carry out all background checks deemed appropriate through
this I also authorize the Company to contact any of my former employers as indicated above and carry out all background checks deemed appropriate throu gh this
selection procedure. I authorize my former employers, agencies, educational institutes etc. to release information pertaining to my employment / education and

release them from any liability in doing so.

Date Place Signature

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 Bank Details

Bank Name Bank Account Number IFSC Code Branch Name

PF / UAN Details / ESIC (Details for Last Company Worked with)

Company Name PF Number UAN Number ESIC Number

DECLARATION & AUTHORIZATION :

I confirm that the stated information is correct to the best of my knowledge and I understand that any misrepresentation of i nformation in this application form

may, in the event of my obtaining employment, result in action based on Company policy.

I acknowledge and understand that my personal information is being collected by the company and this information will be used for internal and official purposes.
I hereby consent to the above.

I hereby also authorize the Company to contact any of my former employers as indicated above and carry out all background checks deemed appropriate through
this I also authorize the Company to contact any of my former employers as indicated above and carry out all background check s deemed appropriate through this
selection procedure. I authorize my former employers, agencies, educational institutes etc. to release information pertaining to my employment / education and

release them from any liability in doing so.

Date Place Signature