EMPLOYEE BACKGROUND VERIFICATION FORM

Impact Infotech

Please note that it is mandatory for you to complete the form in all respects. The information you provide must be complete and correct and the same shall be
treated in strict confidence.
Please fill in the form with CAPITAL LETTERS.
The details on this form will be used for all official requirements should you join the organization.
Position applied for Employee Code Location

Candidate's Email ID (If applicable)

Personal Information
Full Name (First, Middle, Last) Former Name / Maiden Name
(if Applicable)

Father's Name Date of Birth (dd/mm/yy)

Gender Pan Number (if applicable) Nationality Marital Status

Male
Female
Current Address Period of From (mm/yy) To (mm/yy) Residence Number
stay

Pincode
Prominent Landmark Mobile number

Permanent Address Period of From (mm/yy) To (mm/yy) Residence Number

stay

Pincode
Prominent Landmark Mobile number

Education Qualification - Please attach copy of Degree and Final year mark sheet
Dates Attended Qualification Gained ID /Roll No
College Name & Address University Name & Address
From To
dd/mm/yy dd/mm/yy Name of the
Degree
Major Full Time
Year of Passing Part Time

College Name & Address University Name & Address Dates Qualification Gained ID /Roll No
Attended
From To
dd/mm/yy dd/mm/yy Name of the
Degree
Major Full Time
Year of Passing Part Time

Please tick mark the documents submitted for this qualification along with this form
Marksheet Provisional Certificate Degree Certificate None

Employment History- Current Employment

Current Employment
Name of Current Employer Address of Current Employer

Telephone No Employee Code/No Designation Department

HR Name &
Designation HR Contact Number & Email ID

Employment Period Manager's Name Manager's Contact No Can a reference taken now?
From To
Manager's Email ID Yes
No
Duties & Responsibilities Reasons for leaving

First Salary drawn Was this Position Agency Details (if temporary or contractual), provide details
Permanent
Last Salary drawn Temporary
Contractual
Please tick mark the documents submitted for this employment
Service Certificate Relieving letter Offer letter Any Other
None (please specify)
Previous Employment History - Please attach a copy of your relieving letter/service certificate

Note: Please ensure that you are descriptive wherever necessary – e.g. If company has closed, do mention it. Employee Code/ ID/ Number is mandatory. If your previous
employer did not provide one, please mention and state reasons for the same.
Name of Employer (1) Address of Employer

Telephone No Employee Code/No Designation Department

HR Name &
Designation HR Contact Number & Email ID

Employment Period Manager's Name Manager's Contact No

From To
Manager's Email ID

Duties & Responsibilities Reasons for leaving

First Salary drawn Was this Position Agency Details (if temporary or contractual), provide details
Permanent
Last Salary drawn Temporary
Contractual
Please tick mark the documents submitted for this employment
Service Certificate Relieving letter Offer letter Any Other
None (please specify)

Previous Employment History - Please attach a copy of your relieving letter/service certificate
Name of Employer (2) Address of Employer

Telephone No Employee Code/No Designation Department

HR Name &
Designation HR Contact Number & Email ID

Employment Period Manager's Name Manager's Contact No

From To
Manager's Email ID

Duties & Responsibilities Reasons for leaving

First Salary drawn Was this Position Agency Details (if temporary or contractual), provide details
Permanent
Last Salary drawn Temporary
Contractual
Please tick mark the documents submitted for this employment
Service Certificate Relieving letter Offer letter Any Other
None (please specify)

References: Please provide the details of professional reference (Any two, who are not your relatives)
Reference (1)
Name & Position held:
Email Address:
Contact Number:
How do you know this person?

Reference (2)
Name & Position held:
Email Address:
Contact Number:
How do you know this person?
Functional Entity Gap Duration (Please specify MM/YYYY to MM/YYYY) Gap Reason

Between Education to Employment

Between Employment to Employment

Between Employment to Employment

Between Employment to Employment

Other reason :  (This may be medical
reason /family reason/ or any other,
 with the duration )
Note:-Kindly submit supporting document for the gaps mentioned above
Documents Required (Mandatory)
Education:
Photocopy of degree certificate and final mark sheet of all examinations

Employment
Photocopy of relieving / experience letter for each employer mentioned in the form

Identity
Pan Card / Passport Copy/ Driving License
Declaration and Authorization (Only Manual signature is acceptable for Verification)

I hereby authorize A-Check Global Solutions Private Limited and its representative to verify information provided in my application for employment and this employee background verification
form, and to conduct enquiries as may be necessary, at A-Check’s discretion. I authorize all persons who may have information relevant to this enquiry to disclose it to A-Check Global
Solutions Private Limited or its representative.

I release all persons from liability on account of such disclosure.

This authorization and release, in original, faxed, photocopied form or e-mail transmission, shall be valid for this and any future reference. I confirm that the above information is correct to
the best of my knowledge.

Signature:

Name: Date:

(Please Select this declaration and authorization, take this page printout and sign it manually)