Background verification form

BACKGROUND VERIFICATION FORM CONFIDENTIAL
Please ensure that the details provided on this form are correct and complete in all respects, as this information will be used for
background screening purposes and all other official requirements.
FIRST NAME MIDDLE NAME SURNAME
KULANDAISELVAN V
PERSONAL INFORMATION
Date of Birth 2 5 0 4 1
9
8 7 Passport No.
PAN No. CLRPK4031M Father’s Name VARADHARAJAN

Gender MALE Nationality INDIAN
Contact No. 6381947072 Father Mobile No. 9944107378
UAN No. 101685299491 Marital Status SINGLE
Former/Maiden Names
Date(s) of Name Change
(if applicable)
Permanent Address Current Address
Same as permanent YES NO (If No, write complete address)
3/51,4th street
SHANTHINAGAR
PALAYAMKOTTAI
TIRUNELVELI
TAMILNADU
INDIA
PIN CODE 627002 PIN CODE
Residing From Residing From
Residing To Residing To
Contact No. 6381947072 Contact No.

Page no.1 of 7

EDUCATIONAL QUALIFICATIONS
§ Please provide degree/diploma equivalent qualifications or higher are to be provided.
§ Please attach copies of all years’ marks sheets & degree certificates (Graduation and onwards)
Dates Attended (MM YY) Name &
ID/Roll
Level Qualification Mode Address of University
From To No.
Institute/College
Full Time
SRIRAM
ENGG
Qualification 1
ME Part Time
2009 2011 COLLEGE
Distance
Please tick mark the documents submitted for this qualification:

All Year Mark Sheets Degree Certificate Provisional Certificate None
Full Time
Qualification 2 Part Time
Distance

Full Time
Qualification 3 Part Time
Distance


GAPS IN EDUCATION
Please provide details of all gaps of 1 month or more that you may have between your past qualifications.
Gap From (DD MM YYYY) Gap To (DD MM YYYY) Gap Period (in months) Reason
Page no.2 of 7

EMPLOYMENT HISTORY
§ Please provide employment history for your last (3) employments
§ Start with your most recent/current employer, followed by details of the employment preceding that.
§ Ensure that you are descriptive wherever necessary; e.g., if the company has closed/ceased operations/moved
location, do mention it.
§ Employee Code/ ID/ Number of your previous employer are mandatory.
Name of Employer 1 (Current/Most Recent Employer) Address
Company Contact No.
Employee Code Designation Department
Employment Period From Employment Period To Salary Details
Type of Employment Details of Agency (if deployed from another agency)
Permanent Temporary Contractual
Reason for Leaving Duties & Responsibilities
Reporting Manager Designation & Department Contact No. (Include Extn. #) Email id
Next Reporting Manager Designation & Department Contact No. (Include Extn. #) Email id

Relieving Letter Service Certificate Appointment Letter Salary Slip Others (please specify) None

Page no.3 of 7

Name of Employer 2 Address
Company Contact Nos.

Reporting Manager Designation & Department Contact No. (include Extn. #) Email id
Next Reporting Manager Designation & Department Contact No. (include Extn. #) Email id



Please tick mark the documents submitted for this employment:

Page no.4 of 7




GAPS IN EMPLOYMENT (IF ANY)
Please provide details of all gaps of 1 month or more that you may have between your past employments or between leaving
the last employment and joining client company.
GAPS IN STUDIES AND EMPLOYMENT (IF ANY)

Please provide details of all gaps of 1 month or more that you may have between your past employments or between any
qualification to your employments

Page no.5 of 7

PROFESSIONAL REFERENCES
§ Please provide details of 3 references that may be contacted to obtain feedback.
§ Ensure that the references provided are not friends, family members or are employees of the joining organization.
Details Reference 1 Reference 2 Reference 3
Name
Organization Name
Contact No.
Email ID
Occupation (provide details)
Relationship with the Referee
Years you have known the Referee

OTHER INFORMATION
Are you currently engaged in any other business either as a proprietor, partner, officer, director,
trustee, employee and agent or otherwise? If yes, please give details.
Yes No
Have you ever been dismissed from the services of any previous employer(s)? If yes, please
give details.
Yes No
Have you ever been convicted in a court of law or of a criminal offence? If yes, please give
details and status of prosecutions against you.
Yes No
Have you ever had any civil judgments made against you? If yes, please give details.
Yes No
DECLARATION
“I hereby declare that the information I have given is true and correct to the best of my knowledge. I understand that a
misrepresentation or omission of facts called for herein shall be sufficient cause for cancellation of consideration for employment
or dismissal from the Company’s service if I have been employed, without liability to the Company.
“I hereby authorize iVerify and/or its agents to conduct verification of all statements contained in this record if I am considered
for employment. I understand that my employment is subject to satisfactory background verification.”
Date: Name: Signature:

Page no.6 of 7

Please note that iVerify Research Services Private Limited will be conducting your employment background verification
on behalf of your employer. Given below is the Authorization Letter, where you need to sign to authorize for your
background verification. You have right to deny and not sign Authorization letter if you do not want to allow for verification.

I hereby authorize Employer, iVerify Research Services Private Limited and its associated third parties
to make investigation of my background, references, character, past employment, consumer / credit reports, education, Address,
criminal history record etc. which may be any state or local files, including those maintained by both public and private
organizations, and all public records, for the purpose of confirming the information contained on my application and/or obtaining
other information which may be material to my qualification for employment.
A Fax, scan or Xerographic copy of this consent shall be considered as valid as the original consent.
I authorize any individual, company, firm, corporation, or public agency including law enforcement agencies to divulge any and
all information, verbal or written pertaining to me, to employer, iVerify and its Agents. I also hereby authorize the company’s
access to any medical histories or records pertaining to me.
I understand that some or all the information I have provided in this application form will be held as digitized or physical records
as per the data retention period, contractually agreed between employer and iVerify.
I further authorize the complete release of any records or data pertaining to me which the individual, company, firm, corporation,
or public agency may have to include information or data received from other sources.
I understand that any false answers or statements, or misrepresentations by omission, made by me on this application form or
any related document will be sufficient for rejection for my application or for my immediate discharge should such falsification or
misrepresentation be discovered after I am employed.
Note: It is mandatory to duly sign the form on the space provided below or else the application form would be
rejected
Applicant Name: Signature:
Date: Place:
Page no.7 of 7

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BACKGROUND VERIFICATION FORM CONFIDENTIAL

FIRST NAME MIDDLE NAME SURNAME

PAN No. CLRPK4031M Father’s Name VARADHARAJAN

Please tick mark the documents submitted for this qualification:

Qualification 2 Part Time

Please tick mark the documents submitted for this qualification:

Qualification 3 Part Time

Please tick mark the documents submitted for this qualification:

Company Contact No.

Employee Code Designation Department

Employment Period From Employment Period To Salary Details

Type of Employment Details of Agency (if deployed from another agency)

Permanent Temporary Contractual

Reason for Leaving Duties & Responsibilities

Please tick mark the documents submitted for this qualification:

Company Contact Nos.

Employee Code Designation Department

Employment Period From Employment Period To Salary Details

Type of Employment Details of Agency (if deployed from another agency)

Please tick mark the documents submitted for this qualification:

Company Contact Nos.

Employee Code Designation Department

Employment Period From Employment Period To Salary Details

Type of Employment Details of Agency (if deployed from another agency)

Please tick mark the documents submitted for this employment:

Company Contact Nos.

Employee Code Designation Department

Employment Period From Employment Period To Salary Details

Type of Employment Details of Agency (if deployed from another agency)

Please tick mark the documents submitted for this qualification:

GAPS IN STUDIES AND EMPLOYMENT (IF ANY)

Date: Name: Signature:

Applicant Name: Signature:

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