STANDARD INPUT FORM

Present (Residential) and Permanent Address:

Name : _________________________________ ECN: _____

Date of Birth : _______/_______/________ Marital Status: Married / Single

Fathers Name:

Your Present Details:

STD Code Telephone No.

Mobile No.
Email id

1
 Contact Details(Fill In Block Letters)
Current Address
Residence() Owned Parental Rental Hostel/PG With Relative
Building Name
Landlords Name

Flat/House No: Block No/Street No

Street name:

City
District Post Office

State: Pin Code

Landmark

Best time to visit. AM to PM

Permanent Address
Residence() Owned Parental Rental Hostel/PG With Relative
Bldg Name:

Flat/House No: Block No/Street No

Street name:

City
District Post Office

State:
Pin Code

Land Mark

Best Time to visit AM To PM

2
Documents in support of permanent address must be Enclosed/ Not enclosed
enclosed.
Documents in support of current address must be enclosed. Enclosed/ Not enclosed

3
Details of Educational Qualifications

Only the information about Highest Degree i.e. certificates and mark sheet of Graduation or Post Graduation
Degree should be provided. Information about unrecognized degrees and diplomas and Certificate courses
which are availed from Universities / Institutes which are unrecognized should not be provided.

Name & address of the

Institute/College
Name and address of the
university
Name of the Graduation
Degree/Masters degree
Duration of the course
(number of years/months)
Whether examination held
on yearly basis or
semester basis
Total number of semesters
Detail of semesters / In case of (Period From to.) with % In case of (Period From to.)
years (Copies of mark Semester of Marks Yearly with % of Marks
sheets must be attached system exam
for each semesters / Sem 1
Years) Sem 2 1st
Sem 3 2nd
Sem 4
Sem 5 3rd
Sem 6 4th
Sem 7
Sem 8 5th
Sem 9
Sem 10

Copies of mark sheets for Enclosed/ Not enclosed

all semesters/years must
be enclosed
Copies of certificate of Enclosed/ Not enclosed
convocation must be
Enclosed
Over all Grade / Class /
Division obtained

4
Information about pervious employments

Sr. Particulars Previous Employment (1) Previous Employment (2)

1 Employers Name and full address
2 Office Landline Numbers, email
address, Fax number.
3 Employee Code or any other specific
identification number allotted by the
employer.
4 Date of Joining (DD/MM/YY)
Date of Leaving (DD/MM/YY)
5 If you have received relieving letters by Yes/ No Yes / No
you previous employer?
6 Copies of appointment letter and Yes/ No Yes/ No
relieving letter should be enclosed.
7 Name of official whom you were
reporting while in that employment.
8 Reporting officials contact details;
Office Landline Number;
Office Fax Number;
Office email Address;
Cell Number:

9 If your supervisor has changed his

employment then contact details of
such supervisor and his current
employment details such as address
cell number, email address, etc.
10 Name of your supervisors supervisor.
11 Contact details of your supervisors
supervisor;
Office Landline Number;
Office Fax Number;
Office email Address;
Cell Number:

12 Job Grade At the At the

time of time
Joining of
Joining
At the
time of At the
leaving time
of
leaving
13 Designation/ Market Designation, for At the At the
example Area Sales Manager time of time
Joining of
Joining
At the
At the
time
time of
of
leaving
leaving

5
 14 Details and break up of monthly gross
Salary as per salary slip
Basic In Rs./- Basic In Rs./-
HRA HRA
DA DA
Conveyance Conveyance
Executive Executive
Allowance Allowance
Traveling Traveling
Allowance Allowance
Mobile Mobile
Allowance Allowance
Any other Any other
Fixed Fixed
Allowance as Allowance as
per Salary per Salary Slip
Slip
Gross as per Gross as per
monthly pay monthly pay
slip slip
15
Reason for Leaving
16 Copies of monthly pay slip attached Yes/ No Yes/ No

Professional Reference

Sr. Details Professional Reference (1) Professional Reference (2)

1 Full Name and address

Contact Numbers & email

2
address

Name and address of the

3 organization where he/she
is currently associated

Job Title / Designation, if

4
any

Name of the Candidate /Employee: Branch/Office:

Designation: Grade:

Signature: Date:

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 AUTHORIZATION NOTE

To whom so ever it may concern

I authorize the Company or the retained third party to obtain investigative Employment Screening report for employment
purposes, including in connection with my application for employment;

Wherein an Employment Screening report includes any information regarding the character, general reputation, personal
characteristics or mode of living of the subject;

Wherein the specific nature and scope of the Employment Screening report includes education Verification (Authentication
of acquired or pursuing Degrees/Diplomas; work history; credit history; court records, including criminal verification
records as permitted by law; Passport Verification; Permanent Account Number verification; Drug Verification; Finger Print
Verification; Address Verification and references from professional and personal associates.

I further understand and agree that the Employment Screening report may be obtained at any time and any number of
times as deigned necessary before during or post my employment with them.

I hereby authorize all previous employers, educational institutions, consumer reporting agencies and other persons or
entities having information about me to provide such information to the Company or any other third party retained by
them for the purpose.

All the information furnished by me in the Job Application Form is true to the best of my knowledge

I understand that the continuance of employment or the offer of employment is contingent upon the outcome of the
background check conducted on me and that this Disclosure & Authorization is not an offer for employment by the
Company or a contract of employment with the Company.

The proof of Identity enclosed and self attested for reference.

A Photostat, or any other copy, of this instrument bearing my signature shall be equally legally valid as the original.

Signature: ________________

Name: ___________________

Date: ____________________

Place: ____________________