STANDARD INPUT FORM

Present (Residential) and Permanent Address:

Name

: _________________________________

Date of Birth

: _______/_______/________

ECN: _____
Marital Status: Married / Single

Fathers Name:
Your Present Details:
STD Code

Telephone No.

Mobile No.
Email id

Contact Details(Fill In Block Letters)

Current Address
Residence()

Owned

Parental

Rental

Hostel/PG

With Relative

Building Name
Landlords Name

Block No/Street No

Flat/House No:

Street name:

City
District

Post Office

Pin Code

State:
Landmark

Best time to visit.

AM

to

PM

Permanent Address
Residence()

Owned

Parental

Rental

Hostel/PG

Bldg Name:
Block No/Street No

Flat/House No:

Street name:

City
District

Post Office

State:

Pin Code

Land Mark
Best Time to visit

AM

To

PM

With Relative

Documents in support of permanent address must be

enclosed.
Documents in support of current address must be enclosed.

Enclosed/ Not enclosed

Enclosed/ Not enclosed

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 /
years (Copies of mark
sheets must be attached
for each semesters /
Years)

In case of
Semester
system
Sem 1
Sem 2
Sem 3
Sem 4
Sem 5
Sem 6
Sem 7
Sem 8
Sem 9
Sem 10

(Period From to.) with %

of Marks

In case of
Yearly
exam
1st
2nd
3rd
4th
5th

Copies of mark sheets for

all semesters/years must
be enclosed
Copies of certificate of
convocation must be
Enclosed
Over all Grade / Class /
Division obtained

Enclosed/ Not enclosed

Enclosed/ Not enclosed

(Period From to.)

with % of Marks

Information about pervious employments

Sr.
1
2
3
4
5
6
7
8

Particulars
Employers Name and full address
Office Landline Numbers, email
address, Fax number.
Employee Code or any other specific
identification number allotted by the
employer.
Date of Joining (DD/MM/YY)
Date of Leaving (DD/MM/YY)
If you have received relieving letters by
you previous employer?
Copies of appointment letter and
relieving letter should be enclosed.
Name of official whom you were
reporting while in that employment.
Reporting officials contact details;
Office Landline Number;
Office Fax Number;
Office email Address;
Cell Number:

10
11

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.
Name of your supervisors supervisor.
Contact details of your supervisors
supervisor;
Office Landline Number;
Office Fax Number;
Office email Address;
Cell Number:

12

Job Grade

Previous Employment (1)

Previous Employment (2)

Yes/ No

Yes / No

Yes/ No

Yes/ No

At the
time of
Joining
At the
time of
leaving

13

Designation/ Market Designation, for

example Area Sales Manager

At the
time of
Joining
At the
time of
leaving

At the
time
of
Joining
At the
time
of
leaving
At the
time
of
Joining
At the
time
of
leaving

14

Details and break up of monthly gross

Salary as per salary slip
Basic
HRA
DA
Conveyance
Executive
Allowance
Traveling
Allowance
Mobile
Allowance
Any other
Fixed
Allowance as
per Salary
Slip
Gross as per
monthly pay
slip

15
16

In Rs./-

Basic
HRA
DA
Conveyance
Executive
Allowance
Traveling
Allowance
Mobile
Allowance
Any other
Fixed
Allowance as
per Salary Slip
Gross as per
monthly pay
slip

Reason for Leaving

Copies of monthly pay slip attached

Yes/ No

Yes/ No

Professional Reference

Sr.

Details

Full Name and address

Contact Numbers & email

address

Name and address of the

organization where he/she
is currently associated

Job Title / Designation, if

any

Professional Reference (1)

Professional Reference (2)

Name of the Candidate /Employee:

Branch/Office:

Designation:

Grade:

Signature:

Date:

In Rs./-

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: ____________________