INTERVIEW PERSONAL DETAIL FORM

S No Details Response

1 Your name Aathithyan Jagatheesan

2 Contact number 8754111430

3 Gender Male

4 Nationality India

5 PAN Card Number BQTPA3486N

6 Aadhar Number 484382622657

7 Email ID suddenaathi007@gmail.com

Source of Hire (Please choose one of the below and add the relevant
8 details)
Consultant (if Yes), write the name of the
8(a) consultant. No

8(b) Contacted by HR TA Team (Yes/No) No

8(c 1) Employee Reference (if Yes).

Name of Employee Who referred you Yes – (Sanjay Kumar)

8(c 2) Employee ID of the referred person 59267

Job Portal (if Yes). Write the
8(d) name of the website. No
Social Media (if Yes).
Write the name of the social media such as
8(e) facebook/linked/whatapp/etc No
9 Are you an ex-employee of Omega Healthcare?
If so, please mentioned the

Previous Emp. ID 58134

 1yrs
Previous Work Tenure with Omega

Declaration: -
I .…. hereby declare that the information furnished above is true, complete and correct
to the best of my knowledge and belief. I understand that in the event of my information
being found false or incorrect at any stage, my candidature / appointment shall be liable
to cancellation / termination without notice or any compensation in lieu thereof.
Place: - Palani
Date : - 04/10/2021.
Signature: -
 Omega Healthcare Management Services Pvt. Ltd.

BACKGROUND VERIFICATION FORM

Ref

Educational qualification: (Highest Degree)

Full Name Aathithyan Jagatheesan Male Marital Status: Single

Date of Birth: 14/09/1995 Nationality India Father's name: Jagatheesan
Employee No: - Designation: Senior Executive AR

Place of joining: Chennai Date of Joining: 04/10/2021

Current Residential Address: 159/182, Kalliamman Kovil
Street,Kurumbapatti, Adivaram,Palani -624601

Period of stay at current address: From: 14/09/1995

Telephone (Home): - Mobile: 8754111430

Email address: suddenaathi007@gmail.com

Permanent address: 159/182, Kalliamman Kovil

Street,Kurumbapatti, Adivaram,Palani -624601

Telephone: - Mobile: 8754111430

(Important: Copy of Mark sheet and Degree certificate MUST be attached)

College name Karpagam University

 College Address Coimbatote

University Name and address Karpagam University

From — To Graduated Program Student ID/ Enrolment No

(Month / Year)

06/2013 – 04/2016 BCA

Type of degree : Arts & Science Graduation date Major Subject

Computer Application

Employment History — (Relieving letter copy to be attached till last but one employer)

Company Name: Omega Healthcare Position Held& Executive – Sr

Executive AR
Telephone

Employment date: ( Date, Month , Year) From: Employee code: 58134

14/09/2020

Whether employment is temporary or permanent in Nature Permane

nt
Agency details ( If temporary or Contractual)

Responsibilities:

Remuneration: Reason for leaving: Health

Issue
Reported to: name, Position & Contact

Ref: OMH-FOR-HRD-004-V1.O

Company Name: Wave Online Infoway Position Held& Dept Sr Executive AR

 Address( Main office & Branch where worked) Telephone

Coimbatore

Employment date: ( Date, Month , Year) From: Employee code:

01/01/2019

Whether employment is temporary or permanent in Nature Permane

nt
Agency details ( If temporary or Contractual)

Responsibilities:

Remuneration: Reason for leaving: Salary

Growth
Reported to: name, Position & Contact

Can reference check be done: Yes

Name and contact details of 2 referees 1.

2.

Ref : OMH-FOR-HRD-004-V1.O
 Letter of Authorization

To Whomsoever it may Concern

I hereby Authorize Omega Healthcare Management Services Pvt Ltd and its authorized representatives to
verify information provided in my resume and application of employment, and to conduct enquiries as
may be necessary, at the company’s discretion. I authorize all persons who may have all information
relevant to this enquiry to disclose it to Omega Healthcare Management Services Pvt Ltd or its
representative. I release all persons from liability on account of such disclosure.

I Hereby authorize concerned authorities to dispatch my confidential report to Omega Healthcare

Management Services Pvt Ltd or its authorized representative.

Signed :

Name : Aathithyan Jagatheesan

Date : 04/10/2021

** As is the procedure followed by most police departments across India for criminal back ground
verification, It is possible that Police authorities may contact or visit the stated residence and at times
even ask to be physically present at the concerned Police station. It is part of the standard verification
Procedure.
 UNDERTAKING NON-DUAL EMPLOYMENT

I, Aathithyan Jagatheesan hereby declare that I will be under FULL TIME employment through WORK
FROM HOME MODEL with Omega Healthcare Management Services Private Limited. I Aathithyan
Jagatheesan also undertake and Acknowledge that I will not be employed either in part time or full time
with any other
Organization during my employment tenure with Omega Healthcare Management Services Private
Limited.

Upon breach of this undertaking my employment with the company shall be terminated immediately
without any prior notice.

I understand and undertake that the Company shall initiate appropriate legal action against me for any
loss caused to the company either direct or indirect resulting due to my acts breaching this undertaking.

Read and understood above and I accord my consent and willingness.

Signature :

Name : Aathithyan Jagatheesan

Date : 04/10/2021
Letter of Undertaking - WFH

Self-Declaration – System Configuration & Conducive Infrastructure

I undertake that I have sufficient space at my place of stay to accommodate and keep systems
allotted by the company, and I shall not claim for any additional remuneration towards same

I also understand and undertake that I have obtained internet Broad Band services with good
connectivity speed at my cost and same shall be used as connectivity for work production, in
addition to same I also have power backup and I shall not claim for any sort of reimbursement
towards claim of internet broadband and power back.

Name of the Candidate: Aathithyan Jagatheesan

Date: 04/10/2021

Signature of the Candidate:

 Self-Declaration - Acknowledgement form

Transportation Policy:

In Lieu with the offer extended from “Omega Healthcare Management Services Pvt Ltd” for the
role”Senior Executive AR”, I Aathithyan Jagatheesan hereby acknowledge & accept that I have been
informed on the below mentioned transportation clauses before my DOJ, 04/10/2021.

1. Considering the current Covid19 pandemic situation, I understand that company has enabled
WORK FROM HOME facility and I DON’T require any cab/Transportation Facilities until the
lockdown is lifted.
2. If the situation comes back to normalcy and if I’m required to report and work from office,
below mentioned shall be applicable and I am informed about the same
• Rs.750 (As per current policy) would be deducted from my salary pay in case I opt for company
transport
• That transportation for night shift employees (5:30PM to 2:30PM – As per the current policy) is
MANDATORY for Women employees & OPTIONAL for MALE Employees.
• That transportation for Night shift employees (5:30PM to 2:30PM – As per the current policy) is
both to & fro, and I am also aware that Pickup would be at common point and drop would be at
door step.
• That I would be eligible for CAB only if I work in Night shift (5:30PM to 2:30PM – As per the
current policy)
• I understand if I plan to shift my residence after joining Omega, I will confirm the availability of
cab from the Admin team before shifting my residence
3. My current residential address:

159/182, Kalliamman Kovil Street,Kurumbapatti, Adivaram,Palani -624601

4. That transportation for night shift employees are provided within boundaries as explained at the
time of interview. The same will be confirmed by the Admin team if it falls within the boundary
limits at the time of providing transport when reporting into office premises
5. I’m also aware that If my address falls outside the Boundary limits according to the transport
policies of Omega Healthcare Management Services PVT LTD, I will change my residential
location/address within the boundary limits, failing to do will result in termination of services

I Aathithyan Jagatheesan hereby declare that I understood the transportation policy of Omega, and will
be lonely held responsible in case of any deviations.
 Work from Office

Congratulation on your offer!!! And Welcome to Omega family.

As part of salary discussion you had agreed to be available to work from office starting last week
of Mar2021 and you do not have any objection on this matter.
Please confirm the same for us to formally on board you on rolls of Omega.

Name of the Candidate: Aathithyan Jagatheesan

Date: 04/10/2021

Signature of the Candidate: