Professional Documents
Culture Documents
PHOTOGRAPH
APPLICATION FOR EMPLOYMENT HERE
POSITION APPLIED :
SOURCE:
1. NAME FATHER / HUSBAND'S NAME :
3. PRESENT ADDRESS:(Complete address with detailed nearest landmark, street name) CONTACT NO. &
EMAIL: (specify
code)
CITY:
STATE:
PIN CODE:
4. PERMANENT ADDRESS (Complete address with detailed nearest landmark, street name) CONTACT NO. &
EMAIL: (specify
code)
CITY:
STATE:
PIN CODE:
5. HAVE YOU BEEN INTERVIEWED BY ICICI LOMBARD OR ANY OF ICICI GROUP COMPANY? IF YES, NAME OF THE COMPANY
OUTCOME:
7. HAVE YOU BEEN CRIMINALLY PROSECUTED OR HAVE ANY POLICE OR LEGAL CASE GOING ON AGAINST YOU OR FILED
BY YOU? PLEASE GIVE DETAILS:
FATHER
MOTHER
SPOUSE
TO (DD/MM/YYYY) / TILL
1 DATE :
PLEASE CONFIRM IF ANY FAMILY MEMBER (INCLUDING RELATIVES) IS CURRENTLY EMPLOYED WITH ICICI LOMBARD
OR ICICI GROUP OR HAS ANY BUSINESS ASSOCIATION WITH ICICI GROUP:
1 RELATIONSHIP :
TEL No:
OFFICIAL EMAIL ID:
2 RELATIONSHIP :
TEL No:
OFFICIAL EMAIL ID :
3 RELATIONSHIP :
TEL No:
OFFICIAL EMAIL ID:
LANGUAGES KNOWN
DECLARATION
With reference to my application for an appointment in the services of ICICI General Insurance Company Limited
(Company), I hereby declare and undertake the followings:
There is no case pending against me in any Court of Law or in any Police Station. Further, there was no FIR/
Investigation against me in the past and I was never arrested and or convicted in any Court of Law.
If yes, please mention details of such pending case(s) and or reasons leading to such FIR / Investigation / arrest /
conviction in the past including period of detention, if any
I hereby authorize ICICI Lombard GIC Ltd (Or a third party agent appointed by the Company) to contact any former
employers as indicated above and carry out all background check not restricted to education and employment deemed
appropriate through this selection procedure. I authorize former employers, agencies, educational institutes etc. to
release any information pertaining to my employment/education and I release them from any liability in doing so.
I confirm that the above information is correct to the best of my knowledge and I understand that any misrepresentation
of information on this application form, in the event of my obtaining employment, may result in action based on
Company policy.
Signature:
Name:
Date:
PAN No: