1CS Conf|dent|a| age | 10

8ackground Check Iorm

Gu|de||nes ]Check||st
- ?our 1ralneeshlp !ob Cffer ls sub[ecL Lo successful compleLlon of 8ackground verlflcaLlon
- llll-up Lhe 8CC lorm compleLely and accuraLely wlLh coples of all relevanL supporLlng
documenLs as proof
- 'unable Lo verlfy' due Lo lncorrecL or lncompleLe lnformaLlon furnlshed by you may lead Lo
delays and/or unsuccessful compleLlon of 8CC
- Lnsure conslsLency ln lnformaLlon furnlshed by you lnlLlally ln 1CS AppllcaLlon lorm
_____________________________________________________________________________________

1. 1|ck on the boxes be|ow to he|p you ensure a|| requ|red documents are attached before
subm|tt|ng
2. No 8GC forms w||| be accepted |n the absence of any of the requ|red documents as ment|oned
be|ow.

Mandatory Genera| kequ|rements:
! Slgned & ALLached uocumenL on Ceneral ConsenL Lo 8ackground lnvesLlgaLlon LeLLer
(8CC ConsenL LeLLer enclosed wlLhln Lhe 8CC form)
! My recenL assporL slze phoLograph pasLed aL Lhe approprlaLe place

Address Check & Cr|m|na| Check kequ|rements:
! CompleLe & CorrecL Address fllled-ln as requlred ln 8CC lorm wlLh llaL/8oom no. clearly
menLloned
! romlnenL landmark near Lhe address menLloned for easy locaLlon
! Self-aLLesLed & slgned - uocumenL for Address roof submlLLed

What cou|d be subm|tted for Address roof?
- roof for resenL & ermanenL Address Lo be aLLached
- rovlde SeparaLe roof, lf address ls dlfferenL
- ALLach copy of any one of Lhe followlng documenLs as roof for Address

(a) 8aLlon Card (b) LlecLrlclLy 8lll (c) Landllne 1elephone 8lll (Moblle ph blll noL accepLable)
(d) Pouse Lease AgreemenL (e) valld assporL

- If your resent Address ] Address of Longest Stay |n the |ast 7 years ] ermanent Address |s |n
Mumba| ] 1hane C|ty ] 1hane kura| ] une, subm|t the fo||ow|ng documents:

! Clu lorm as appllcable for Lhe locaLlon - lllled-ln wlLh all deLalls
! 2 hoLos wlLh my name wrlLLen aL Lhe back of each phoLo
! Address roof (any one of Lhe followlng) - Copy of 8aLlon card / LlecLrlclLy blll/Landllne
1elephone blll


1CS Conf|dent|a| age | 11

- Address roof ! Ior nouse Lease Agreement
! Copy of AgreemenL submlLLed (lf AgreemenL slgned beLween you and Cwner)
! Copy of AgreemenL + ueclaraLlon LeLLer ln SLamp aper from AgreemenL Polder (8lood
8elaLlon) sLaLlng LhaL l am resldlng ln Lhe same address as menLloned ln Lhe AgreemenL (lf
AgreemenL slgned beLween your lamlly Member (8lood 8elaLlon) and Cwner)
! LeLLer from SocleLy of Lhe address (lf AgreemenL slgned beLween any oLher person (non-
blood 8elaLlon) or you are sLaylng ln 8achelor's AccommodaLlon)

!"#$%&'"(&)**&+",-$&.$)-$&/0($$1$2#-3&4",&-5",*6&5)7$&-#)4$6&)#&*$)-#&8&1"2#5-&92&#5$&/66($--&
1$2#9"2$6&)26&#5$&/0($$1$2#&-5",*6&:$&7)*96&)26&;9#592&#5$&$<=9(4&6)#$&
! SeparaLe Clu lorm fllled ln & aLLached for each dlfferenL address (lor AppllcanLs from
Mumbal, 1hane ClLy, 1hane 8ural & ane- lull Addresses and SlgnaLure glven ln each)
!"#$%&'"(1-&2"#&-902$6&:4&#5$&/==*9>)2#&)($&2"#&)>>$=#$6&:4&#5$&?"*9>$&@"(&7$(9@9>)#9"2&
/==*9>)2#-&#"&($="(#&)#&?"*9>$&-#)#9"2&;5$2&>)**$6&@"(&)-&=)(#&"@&7$(9@9>)#9"2&=(">$--&:4&?"*9>$&
&
Demand Draft of ks.100]- as requested |n the CID form need not be attached.

ID Check kequ|rements
! Self-aLLesLed & slgned - uocumenL for lu roof submlLLed

What cou|d be subm|tted for ID proof?
(a)valld assporL (b) urlvlng Llcense (c) An Card (d) voLer's lu card (e) College lu Card duly aLLesLed
by PCu/rofessor/1C of Lhe College

keference Check kequ|rements ! Ior each keference
! 8eferences provlded are elLher Supervlsor/PCu / rofessor / 1C/erson holdlng 8esponslble
oslLlon ln a repuLed CrganlzaLlon
- no 8elaLlves/lrlends Lo be menLloned
- 8eference Lo know AppllcanL for a mlnlmum perlod of 2 years
! lull name & Address of 8eferences provlded leglbly
! ConLacL emall lu & Lelephone numbers of 8eferences provlded
- rovlde aL leasL Lwo conLacL numbers

Lducat|ona| Check kequ|rements
! Self-aLLesLed & slgned - coples of PlghesL uegree /rovlslonal uegree submlLLed
! Self-aLLesLed & slgned -coples of all PlghesL uegree mark sheeLs aLLached

Gaps dur|ng Lducat|on ] Lmp|oyment Check kequ|rements:
! Self-aLLesLed & slgned - uocumenLs Lo explaln gaps durlng LducaLlon/LmploymenL

What cou|d be subm|tted as roof for gaps dur|ng Lducat|on]Lmp|oyment?
- Medlcal records for gaps due Lo medlcal reasons
- AffldavlL wlLh noLary AuLhorlzaLlon for gaps due Lo oLher ersonal reasons
/==*9>)2#&#"&=*$)-$&6$#)>5&)26&6$-#("4&#59-&>5$>A*9-#&;59*$&-,:19##920&#5$&>"1=*$#$6&BCD&'"(1&

1CS Conf|dent|a| age | 12




8 8A AC Ck kG Gk kC CU UN ND D C Cn nL LC Ck k I IC Ck kM M C Ca am mp pu us s 1 1r ra a| |n ne ee es s ( (C C1 1) )
a as sL Le e y yo ou ur r r re ec ce en nL L
a as ss sp po or rL L S Sl lz ze e
h ho oL Lo o h he er re e
1CS App||cant ID:
C1 keference number:
1CS Cffer 8ef no./uaLe: 1CS 8ecrulLmenL 8ranch:
ueslgnaLlon:
name of Lhe AppllcanL (lull name expandlng lnlLlals):

ConLacL Landllne hone no.: Moblle hone no. emall ld:
laLher's name:
uaLe of blrLh (ALLach roof): MarlLal SLaLus: Slngle / Marrled naLlonallLy:
A. resent kes|dent|a| Address : (Attach roof)
er|od of Stay lrom : 1o: Landmark:


ClLy/1own: SLaLe: ln code:
8. Cther kes|dent|a| Address: [Iurn|sh other addresses of your res|dence |n the |ast seven (7) years]
Cther kes|dent|a| Address 1: Cther kes|dent|a| Address 2: Cther kes|dent|a| Address 3:
lrom : 1o: lrom : 1o: lrom : 1o:



ClLy/1own: ClLy/1own: ClLy/1own:
SLaLe: SLaLe: SLaLe:
ln code: ln code: ln code:
Landmark: Landmark: Landmark:
Attach Add|t|ona| Sheet, |f you have stayed |n more than 3 Cther kes|dent|a| addresses (|ocat|ons)
C. ermanent Address: (Attach roof)
er|od of Stay lrom : 1o: Landmark:


ClLy/1own: SLaLe: ln code:
ConLacL Landllne hone no.: Moblle hone no.:

1CS Conf|dent|a| age | 13

Is any case pend|ng aga|nst you |n any court of Law at the t|me of f||||ng up th|s 8ackground Check
Iorm?
?es / no

Is any case pend|ng aga|nst you |n any Un|vers|ty or any other educat|ona| author|ty ] |nst|tut|on
at the t|me of f||||ng up th|s 8ackground Check Iorm?
?es / no

"#$%&'$()*+',$%-$().$-#$%&'$(/-0'$1')%2-)'3$45'*%2-)*$2*$6$7'*8$920'$#5::$;(,%2<5:(,*$-#$%&'$<(*'$
]arrest ] detent|on] I|ne ] conv|ct|on ] sentence ] pun|shment etc. And ] or the nature of the case
pend|ng |n the Court ] Un|vers|ty ]Lducat|ona| Author|ty etc., at the t|me of f||||ng up th|s form.
(Attach add|t|ona| sheet, |f requ|red)


assport Deta||s (Attach roof):




Lducat|ona| ua||f|cat|ons (Attach roof):

Name as |n Cert|f|cate: ______________________________________________________________



























(l) name as ln assporL: ________________________________________________________________

(ll) assporL no: __________________________ (lll) lace of lssue: _________________________

(lv) uaLe of lssue: ___________________________ (v) uaLe of Lxplry: ________________________

1CS Conf|dent|a| age | 14

Dec|arat|on and Genera| Consent to 8ackground Invest|gat|on
1o be s|gned by the App||cant

ln connecLlon wlLh my appllcaLlon Lo render servlces Lo 1aLa ConsulLancy Servlces LLd (Lhe
"Company"), l hereby agree as follows:

l cerLlfy LhaL Lhe lnformaLlon furnlshed ln Lhls form as well as ln all oLher forms fllled-ln by me ln
con[uncLlon wlLh my Lralneeshlp ls facLually correcL and sub[ecL Lo verlflcaLlon by 1CS lncludlng
8eference Check and 8ackground verlflcaLlon.

l accepL LhaL an appolnLmenL glven Lo me on Lhls basls can be revoked and/ or LermlnaLed wlLhouL
any noLlce aL any Llme ln fuLure lf any lnformaLlon has been found Lo be false, mlsleadlng,
dellberaLely omlLLed/ suppressed.

As a condlLlon of Company's conslderaLlon of my appllcaLlon for Lralneeshlp wlLh Lhe Company, l
hereby glve my consenL Lo Lhe Company Lo lnvesLlgaLe or cause Lo be lnvesLlgaLed Lhrough any Lhlrd
parLles my personal, educaLlonal and pre or posL [olnlng hlsLory. l undersLand LhaL Lhe background
lnvesLlgaLlon wlll lnclude, buL noL be llmlLed Lo, verlflcaLlon of all lnformaLlon glven by me Lo Lhe
Company. l conflrm LhaL Lhe Company ls enLlLled Lo share such lnvesLlgaLlon reporL wlLh lLs cllenLs Lo
Lhe exLenL necessary ln connecLlon wlLh Lhe Servlces, whlch l may be requlred Lo provlde Lo such
cllenLs. l conflrm and underLake LhaL Lhe Company shall lncur no llablllLy or obllgaLlon of any naLure
whaLsoever resulLlng from such lnvesLlgaLlon or sharlng of Lhe lnvesLlgaLlon resulLs as above.

l cerLlfy LhaL l am aL presenL ln sound menLal and physlcal condlLlon Lo underLake employmenL wlLh
1CS. l also declare LhaL Lhere ls no crlmlnal case flled agalnsL me or pendlng agalnsL me ln any CourL
of law ln lndla or abroad and no resLrlcLlons are placed on my Lravelllng anywhere ln lndla or abroad
for Lhe purpose of buslness of Lhe company.

l Agree : ?es

SlgnaLure _____________________________________

name _____________________________________

1CS AppllcanL lu _____________________________________

lace _____________________________________

uaLe _____________________________________




1CS Conf|dent|a| age | 1S

Gaps dur|ng Lducat|on (Attach roof):


DLCLAkA1ICN (1o be s|gned by the App||cant)


l cerLlfy LhaL Lhe lnformaLlon furnlshed ln Lhls form ls facLually correcL and compleLe ln all respecLs
Lo Lhe besL of my knowledge and bellef.


lace ______________ SlgnaLure of AppllcanL ___________________________________

uaLe ______________ name __________________________________________________

























Irom 1o keasons for gap
Gap er|od 1









Gap er|od 2









1CS Conf|dent|a| age | 16

|ease attach the fo||ow|ng documents a|ong w|th th|s 8ackground Check Iorm:

1. our recent assport s|ze photograph pasted at the appropr|ate p|ace

2. Se|f-attested & S|gned Copy of Ident|ty roof document:
- valld assporL / urlvlng Llcense / An Card / voLer's lu card /College lu Card duly aLLesLed by
PCu/rofessor/1C of Lhe College

3. Se|f-attested & S|gned Copy of Address roof document:
- 8aLlon card / LlecLrlclLy blll / Landllne 1elephone blll / valld passporL
- Pouse Lease AgreemenL + 8elaLed uocumenLs as requlred
- PosLel AlloLmenL LeLLer from College, lf sLaylng ln College PosLel

4. Se|f-attested & S|gned Copy of Lducat|ona| Cert|f|cates:
- PlghesL uegree CerLlflcaLe(s) /rovlslonal uegree CerLlflcaLe(s)
- PlghesL uegree Mark sheeLs of all exams

S. Se|f-attested & S|gned ! Documents to exp|a|n gaps dur|ng Lducat|on
- ALLach AffldavlL wlLh noLary AuLhorlzaLlon for gaps
E?*$)-$&($@$(&B)>A0(",26&D5$>A&'"(1&C,96$*92$-FD5$>A*9-#&92&G5$$#&HI&J&HH&@"(&1"($&6$#)9*-K&
&
Ior Cff|ce Use Cn|y:
verlfled Lhe followlng:
- 8CC ConsenL LeLLer - slgned & aLLached
- 8ecenL assporL slze phoLo pasLed aL Lhe approprlaLe place
- 8CC lorm fllled-ln wlLh all compleLe deLalls
- Address & lu roof documenLs self-aLLesLed, slgned & aLLached
- PlghesL uegree CerLlflcaLe(s)/rovlslonal uegree CerLlflcaLe(s) - coples self-aLLesLed, slgned &
aLLached
- PlghesL uegree Mark sheeLs of all exams - coples self-aLLesLed, slgned & aLLached
- uocumenLs Lo explaln gaps durlng LducaLlon/LmploymenL - aLLached

nk kecru|tment kepresentat|ve:

name: ____________________________ Lmployee number: ____________________

SlgnaLure: ____________________________ uaLe: ____________________