Background Verification Form

Employee Code Employee Location

PERSONAL DETAILS

Name of Applicant : SAMEEKSHA JAIN

Surname: JAIN

Middle-PUKHRAJ

First-SAMEEKSHA

Maiden Name : SAMEEKSHA JAIN

Have you ever been known by another name?

YES NO

If Yes, please write the other name:

NO.

Place of Birth: AJMER Date of Birth (dd/mm/yy): 02/04/1989

Sex: FEMALE Nationality: INDIAN

Father’s Name:

PUKHRAJ JAIN

Passport No.G8827222 SSN No.

(Mandatory for US address)

Home Phone- O2974-210431 Office Phone-02974-228044-228048

Mobile: 09351895873

RESIDENTIAL ADDRESS

Permanent Address: BANK COLONY, PLOT NO. 04, “PARSHAV”

SIROHI DISTRICT

City : ABUROAD State : RAJASTHAN

Pin Code : 307026 Nearest Landmark :

DR.VIKRANT SAKSENA’S RESIDENCE

Name of the contact person at the address :PUKHRAJ JAIN

Relationship of contact person : FATHER

Landline No.02974-210431 Mobile No.09351895873

Nature Of Location: Rented/Owned/Others:

PARENTAL

Preferred time of the day for conducting the verification, if any : DAY TIME

Residing Since (Mandatory):BIRTH Residing Till ( Mandatory):PERMANENT

Current Address

BANK COLONY, PLOT NO. 04,”PARSHAV”

SIROHI DISTRICT

City : ABUROAD State : RAJASTHAN

Pin : 307026 Nearest Landmark : DR. VIKRANT SAKSENA’S RESIDENCE

Contact Person at the address : PUKHRAJ JAIN

Relationship of contact person : FATHER

Landline No.02974-210431 Mobile No.09351895873

Nature Of Location: Rented/Owned/Others:

PARENTAL

Preferred time of the day for conducting the verification, if any : DAY TIME

Residing Since (Mandatory): BIRTH Residing Till ( Mandatory): PERMANENT

Education Record

EDUCATION RECORD ( Start with the latest/ highest qualification; please attach photocopies of the documents ) All fields are mandatory

Name & Address of School/College/Institute

Name & Address of University its affiliated

Type of Degree/Diploma obtained. State “F” for fulltime and “P” for part-time within brackets

Dates Attended

From To

Roll Number/Registration Number/Exam Seat number

HGI, ABUROAD CBSE, NEW DELHI 12TH COMMERCE

FULL TIME

2006

APRIL

2007

MARCH

ROLL NO-1226930

ST.ANSELM’S SCHOOL,

ABUROAD

CBSE, NEW DELHI 10TH

FULL TIME

2004

APRIL

2005

MARCH

ROLL N0-1123933

PROFESSIONAL Education Record

PROFESSIONAL EDUCATION RECORD

( Start with the latest/ highest qualification; please attach photocopies of the documents ) All fields are mandatory

Name & Address of School/College/Institute

(Mandatory)

Name & Address of University its affiliated

(Mandatory)

Type of Degree/Diploma obtained. State “F” for fulltime and “P” for part-time within brackets

Dates Attended

From To

Roll Number/Registration Number/Exam Seat number

SRI BALAJI SOCIETY,BIIB, PUNE

AICTE AFFILIATED,

WESTERN REGION-MAHARASHTRA

PGDM- I.B. & MARKETING.FULL TIME.

2010 JUNE

2012

MAY

ROLL NUMBER-

IB-108135

BKMIBA-HLBBA,

AHMEDABAD

GUJARAT UNIVERSITY

BBA

FULL TIME

2007

JUNE

2010

APRIL

ENROLMENT NUMBER-

200710101189

EMPLOYMENT RECORD

If you are still employed in this organization, please fill in the date before which you would not like the

verification to be initiated in the “To” column. If you are not sure or would like to intimate this date

later, please write 'Still Employed'

Employer 1

Full Name

Employee ID

From (mm/yy) To (mm/yy)

Address Phone Number

City State Country Postal Code

Job Title Reason of Leaving

Designation Final Salary (Annual CTC)

Supervisor Name & Title HR Manager Name

Supervisor ‘s Phone Number HR Manager Phone Number

EMPLOYMENT RECORD

Employer 2

Full Name

Employee ID

From (mm/yy)

To (mm/yy)

Address Phone Number

City State Country Postal Code

Job Title Reason of Leaving

Designation Final Salary (Annual CTC)

Supervisor Name & Title HR Manager Name

Supervisor ‘s Phone Number HR Manager Phone Number

EMPLOYMENT RECORD

Employer 3

Full Name

Employee ID

From (mm/yy)

To (mm/yy)

Address Phone Number

City State Country Postal Code

Job Title Reason of Leaving

Designation Final Salary (Annual CTC)

Supervisor Name & Title HR Manager Name

Supervisor ‘s Phone Number HR Manager Phone Number

EMPLOYMENT RECORD

Employer 4

Full Name

Employee ID

From (mm/yy)

To (mm/yy)

Address Phone Number

City State Country Postal Code

Job Title Reason of Leaving

Designation Final Salary (Annual CTC)

Supervisor Name & Title HR Manager Name

Supervisor ‘s Phone Number HR Manager Phone Number

EMPLOYMENT RECORD

Employer 5

Full Name

Employee ID

From (mm/yy)

To (mm/yy)

Address Phone Number

City State Country Postal Code

Job Title Reason of Leaving

Designation Final Salary (Annual CTC)

Supervisor Name & Title HR Manager Name

Supervisor ‘s Phone Number HR Manager Phone Number

REFERENCE VERIFICATION

REFERENCE VERIFICATION

Note – The reference provided should be currently employed or engaged in a professional activity.

**Please ensure that the contact numbers of the reference are active numbers and are reachable for

verification

PROFESSIONAL REFERENCE (1)

(1)Full name of the Reference

(professional)

SEEMA SINGH ZOKARKAR

Telephone # and email ID email - director@bitmpune.com

 cell 9766644288

Organization SRI BALAJI SOCIETY, BITM -PUNE.

Relationship with the candidate DIRECTOR OF BITM

PROFESSIONAL REFERENCE (2)

(1)Full name of the Reference

(professional)

SATISH M. INAMDAR

Telephone # and email ID EMAIL- sminamdar@yahoo.com

Cell- 9822006297

Organization SRI BALAJI SOCIETY, BIIB-PUNE

Relationship with the candidate DIRECTOR OF BIIB

Information Release Form

To Whom It May Concern:

Please print

I_______________________________________________________________________ Last name First name Middle name

I hereby authorize (Pipal Research subsidiary of CRISIL ) and/or or their authorized representatives and contractors to verify information presented on my employment application/resume and to procure an investigative report or consumer report for that purpose.

I hereby grant authority for the bearer of this letter to access or be provided with full details

n of my previous employment record held by any company or business for whom I previously worked. This information should include the dates of employment; the nature of the position held, [details of my salary upon departure] and an appraisal of my performance, capabilities and character. In addition, please provide any other pertinent information requested by the individual presenting this authority. I hereby release from liability all persons or entities requesting or supplying such information.

n of my qualification/degree (copy of my certificates attached)

n information in respect to my character from the records maintained by local authorities

Signature: Date: dd / mm / yyyy