Authorization form for conducting CIBIL, Address and Educational Checks

I _____________________ hereby give my consent for CIBIL, Address & Education check as

per the policy and authorize concerned authority to conduct the same.

My details required as follows (Details with (*) mark are to be mandatorily filled):

1. *Full Name: _____________________________

2. *PAN Number: ____________________________________ (copy of Pan card as proof)
3. *Date of Birth (DD/MM/YY):______________________________
4. *Residential address: (Current Address)
______________________________________________________________________
______________________________________________________________________
______________________________________ *Pin _____________________________

5. Residence Phone number: _____________________ *Mobile: ________________

6. Bank Name: _______________________ A/c no.___________________________
7. *Permanent address:
_______________________________________________________________________
______________________________________________________________________
_______________________________________ *Pin _____________________________

8 .Highest Qualification- ________________ Year of Completion- ________________

9. Name of the College/ Institute- _________________________________________

10. Board/ University: ___________________________________________________

11. Registration/ Roll Number: ____________________________________________

I hereby declare the information provided is true and I hereby authorize to verify all information
provided by me. My empanelment is subject to satisfactory verification of the above information.

*Date: _____________________ *Name: _________________________

*Signature : ____________________ *Location: __________________________