Personal Data Form

PERSONAL DATA FORM
QFBG1W01 / Ver 3.0
W.E.F. April 15, 2011
Please provide complete and correct information All fields are mandatory Please do not use short forms / abbreviations
Off Ref/Applicant NO
(FOR OFFICIAL PURPOSE ONLY)
Personal Details Full Name (First, Middle, Last) Former Name(s) / Maiden Name (if applicable) Male Female Fathers/Husbands Name Date of Birth ______________ (dd/mm/yyyy)
Gender:
Email ID: .i. .ii.
Residence Number : Mobile Number :
Social Security Number (if applicable)*/ National Insurance Number :

* Social Security Number would be required in case the employee has a past employment and/or education check in the US
Postal Address Please give complete details for further correspondence Line 1: Line 3: District:
* PIN Code is mandatory
Line 2: City: State: PIN Code:

(Mandatory field)**
Page 1 of 5
PERSONAL DATA FORM

Education(Graduation) Please give details of the Highest qualification completed College Name From (dd/mm/yyyy) To (dd/mm/yyyy) Graduated Yes No Qualification attained: Yes No University Name Program Part -Time Full - Time % / Class Subject Major Enrolment No. : No. /Seat
(Mandatory field)**
Graduation date (month/yr) -
** If you are unable to provide the enrolment/seat no., provision of the final year marksheet would be mandatory
Education(Post Graduation) Please give details of the Highest qualification completed College Name From (dd/mm/yyyy) To (dd/mm/yyyy) Graduated Yes No Qualification attained: Yes No University Name Program Part -Time Full - Time % / Class Subject Major Enrolment No. : No. /Seat
(Mandatory field)**
Graduation date (month/yr) -
Please fill details of last 5years of employment

Current Employer (1) Full name and Address of the Company Tele No. Designation & Department Employee Code/ Personnel No.* (Mandatory
field)
Period From (dd/mm/yyyy)
Period To (dd/mm/yyyy)
Reporting Manager (Name & designation)
Salary Details: (Mention CTC / Annum)
Nature of employment (Temporary/Permanent)
Agency Details along with contact numbers (if temporary or contractual)
Salary paid through: Cash / Bank / Cheque Reason(s)for Leaving
Note: The Current Employment Background Check will be initiated after the date of joining at Mahindra Satyam with the above declaration. Associate dont have to give any further authorization for the same, If you have any concern Please inform joining team on the day of Joining.
Page 2 of 5
PERSONAL DATA FORM
Previous Employment History (2) Full name and Address of the Company Tele No.
Designation & Department
Employee Code/ Personnel No.*
Last Reporting designation)
Manager
(Name
&
Salary Details: (Mention CTC or gross) Salary paid through: Cash / Bank / Cheque Reason(s)for Leaving
Manager
(Name
&
Page 3 of 5
PERSONAL DATA FORM

Manager
(Name
&
Salary Details: (Mention CTC or gross)
Salary paid through: Cash / Bank / Cheque Reason(s)for Leaving
Manager
(Name
&
* Provision of employee code is mandatory for all the employments. Request you to provide this information.
Note: Incase of more than 5 employments in the last 5 years kindly mention the details of the same in the above format.
Page 4 of 5
PERSONAL DATA FORM

Declaration and Authorization by Applicant
I consent to take any pre or post-employment examinations as may be required by Mahindra Satyam or its representative, and release Mahindra Satyam from any liability that may arise from such examination. I authorize an inquiry to be made on the information contained on this application. Former employers and officials of universities and colleges named on this application are authorized to give information about me and I release them from all liability for issuing such information. I hereby attest and warrant that all my answers on this application as well as on all forms completed in conjunction with my employment are true and accurate. I understand that my misrepresentation of facts, failure to disclose information required on this application or material change in my information provided which is not reported to Human Resources shall be cause for dismissal regardless of when discovered by Mahindra Satyam.
Signed: Name in Block Capitals:
________________________ ________________________
Date:
________________________
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PERSONAL DATA FORM

QFBG1W01 / Ver 3.0

W.E.F. April 15, 2011

(FOR OFFICIAL PURPOSE ONLY)

Email ID: .i. .ii.

Residence Number : Mobile Number :

Social Security Number (if applicable)*/ National Insurance Number :

Line 2: City: State: PIN Code: