PERSONAL INFORMATION REGISTRATION FORM

Name Surname

Adhaar Number Passport Number

Nationality State/City Personal Picture

Date of Birth Phone number

On-board Date Email

Home Address:

Bank Account Information （for Payroll and T&E）

Bank Name Account holder Name
Account Nos. IFSC Code
PF UAN PAN NO.
Education Background

Highest Degree: Major:

Graduate School: Graduate Year

Working Experience

Reference Contact number of

When Company Position Dept.
person reference

Family & Emergency Contact

Family members

Name Relationship Working company Contact number

Emergency Contact Name: Emergency number:

Declaration

1. Do you have any criminal history or been charged with a crime but result not come yet in Yes
any country?
If yes, please give the details.
 No
2. Have you ever been dismissed by any of your employers? Yes
If yes, please give the details.

No

3. Have you ever signed any agreement (such as termination, Non-complete or non- Yes
solicitation agreement etc.) which limit you to work for PENTAX Medical?
If yes, please give the details copy of agreement.
No

I declare that all information given herein is true and correct. If there exists anything against the actual
situation, I would bear relevant legal liabilities, and company reserve the right to terminate employment
immediately without any payment.
Signature: Date：