Kindly affix a

passport size
APPLICATION FORM photograph here.

PERSONAL DETAILS

Name: Mr. /Ms. /Mx.

Parent’s Name (as mentioned in degree certificate):

Date of Birth (dd/mm/yyyy):

Age:

Nationality:

HAVE YOU BEEN EARLIER INTERVIEWED BY THE FOUNDATION?

IF YES, WHEN AND FOR WHAT ROLE?

CONTACT DETAILS

Address for Correspondence:

Contact Number (please provide at least one landline number)

Office:

Residence:

Permanent Address (if not same as above):

E-MAIL:

134 Doddakannelli, Next to Wipro Corporate Office, Sarjapura Road

Bangalore – 560 035, India
Tel : 91-80-6614 4900 - 02; Fax : 91-80-66144903
 EDUCATION DETAILS

Course/Degree / Key subjects / School / Duration % of Marks / CGPA

Certification specialization College / From – To /Class
Institute and
Location

Post-Graduation

Graduation

XII

Other formal education

Please provide further details on the Post-Graduation and Graduation degree:

Post-Graduation
Name of the Institute / College :
Board/University : Division / Class / % :
Duration of Study (specify month & year): Degree Obtained :

Majored in : Course Type : Regular [ ] Distance [ ]

Address of Institute/School/College City: State:

Pin: Landline :

Graduation
Name of the Institute / College :
Board/University : Division / Class / % :
Duration of Study (specify month & year): Degree Obtained :

Majored in : Course Type : Regular [ ] Distance [ ]

Address of Institute/School/College City: State:

Pin: Landline :

SIGNIFICANT ACHIEVEMENTS: Distinctions, Honors, Awards (Academic, extracurricular) received:

134 Doddakannelli, Next to Wipro Corporate Office, Sarjapura Road

Bangalore – 560 035, India
Tel : 91-80-6614 4900 - 02; Fax : 91-80-66144903
EMPLOYMENT DETAILS

Total Years of Experience:

PRESENT EMPLOYMENT (if not currently working, please state details of last employment)-

Name and address of Organization/Institution:

Domain & nature of business/activities:

No. of employees:

Working Since / Duration: Current Position (Role):

Position reporting to: No. of direct reportees:

Key Responsibilities:

Reasons for seeking change:

Notice period:

Total Monthly Gross Salary (A+B+C): Rs.

(Please state the breakup figures on a monthly basis)

(A) (B) (C)

Basic : Bonus : Provident Fund :

DA / HRA : LTA : Gratuity :

(please specify)
Other Allowances : Medical : Pension / Superannuation:

Performance Incentives: Company car : Any other :

(Fuel, Maintenance, etc) (please specify)
Any other : Any other : Any other :
(please specify) (please specify) (please specify)
Total : Total: Total :

134 Doddakannelli, Next to Wipro Corporate Office, Sarjapura Road

Bangalore – 560 035, India
Tel : 91-80-6614 4900 - 02; Fax : 91-80-66144903
 Expected monthly gross salary: Rs.

PREVIOUS EMPLOYMENT / EXPERIENCE: (Use additional sheets if required)

Sl. Name of the Organization/ Designation / Duration Monthly Gross salary

No. Institution Role From To Drawn – Rs. / Month
Date Date

Any education /employment time-period gaps from the date of passing school (10 th std or equivalent
Examination) to the date of application:

From To How was this time spent?

a) Language Proficiency : Please tick against the language mentioned

Languages Known Speak Read Write

b) Computer Proficiency: (please indicate Operating System and Programs)

134 Doddakannelli, Next to Wipro Corporate Office, Sarjapura Road

Bangalore – 560 035, India
Tel : 91-80-6614 4900 - 02; Fax : 91-80-66144903
c) List the various relevant Development Programmes /Professional courses attended

Institute / Development / Location Dates Conducted by

Organization Professional Program attended
attended From – To

RESEARCH & PUBLICATIONS (if applicable):

ABOUT YOURSELF (in not more than 100 words, each)

Your strengths:

Your areas of improvement:

Your Career objectives:

Expectations from the job:

How would a person close to you describe your five biggest strengths and five biggest development needs?

What is the one thing about yourself you like the most?

134 Doddakannelli, Next to Wipro Corporate Office, Sarjapura Road

Bangalore – 560 035, India
Tel : 91-80-6614 4900 - 02; Fax : 91-80-66144903
 If you could change two things about yourself, what would they be?

In what ways are you different today than five years ago?

Give two references under whom you have either worked / received education from or who know you
professionally.

Sl. Name & E Mail Id Nature of Position Telephone Organization /

No Acquaintance No. (Office Institution
& Res.)

Please indicate your location preferences:

Certification / Authorization

I certify that the information provided in this form is true and correct to the best of my knowledge.

I authorize ‘Azim Premji Foundation’ or its agency to conduct my background verification at an appropriate time.

I understand that if any information furnished by me is found to be false, I could be denied employment / be terminated.

Place: Date:

Signature:

134 Doddakannelli, Next to Wipro Corporate Office, Sarjapura Road

Bangalore – 560 035, India
Tel : 91-80-6614 4900 - 02; Fax : 91-80-66144903
 Confidential when completed

134 Doddakannelli, Next to Wipro Corporate Office, Sarjapura Road

Bangalore – 560 035, India
Tel : 91-80-6614 4900 - 02; Fax : 91-80-66144903