Background Verification Form

Instructions: Please fill the form in BLOCK letters only and do not use any abbreviations
Fields Marked in (*) is mandatory.

Personal Information
*First Name
*Middle Name
*Last Name
Former/Maiden Name
*Nationality
*Gender Male Female
*Marital Status Single Married Others : ____________
*Date of Birth
*Father’s Name
*Personal Landline No *Personal Mobile No.
*Identification Type * Identification No.
(Passport / PAN Card / Driving (Passport / PAN Card / Driving
License / Voter’s Card / Aadhaar License / Voter’s Card / Aadhaar
Card) Card)

National Identity No./

Education Section
Instructions: Fields Marked in (*) is mandatory.

HIGHEST - Qualification 1
*Name of Qualification Obtained
* School/ College/Institute - Name
*School/ College/Institute - Location
School/ College/Institute - Contact No
*University / Board - Name
*University / Board - Location
Enrolment / Roll / Registration
Number
From
*Period of Study
To

Confidential
*Year of Passing *Graduated Yes No Pursuing
*Course Attended Regular / Full Time Part Time Correspondence
Final Year Mark-sheet Degree Certificate (Along with backside if
any)

*Documents Submitted Provisional Certificate Consolidated Marksheet

Other -: ________________

Qualification 2
*Name of Qualification Obtained
* School/ College/Institute - Name
*School/ College/Institute - Location
School/ College/Institute - Contact No
*University / Board - Name
*University / Board - Location
Enrolment / Roll / Registration
Number
M M Y Y
From
*Period of Study M M Y Y
To
*Year of Passing *Graduated Yes No Pursuing
*Course Attended Regular / Full Time Part Time Correspondence
Final Year Mark-sheet Degree Certificate (Along with backside if
any)

*Documents Submitted Provisional Certificate Consolidated Marksheet

Other -: ________________

Last 7 years of complete Address to be mentioned

*City *Postal Code

*State *Country

*Period of Stay
From Date To Date
( DD/MM/YYY)

Address 2 Door no , street name, Area Name & District Name –

Confidential
 *City *Postal Code

*Prominent Landmark

*State *Country

*Period of Stay
From Date To Date
( DD/MM/YYY)

Door no , street name, Area Name & District Name –

*City *Postal Code

*State *Country

*Period of Stay
From Date To Date
( DD/MM/YYY)

Door no , street name, Area Name & District Name –

*City *Postal Code

*State *Country

*Period of Stay
From Date To Date
( DD/MM/YYY)

Door no , street name, Area Name & District Name –

*City *Postal Code

*State *Country

*Period of Stay
From Date To Date
( DD/MM/YYY)

Address 6 Door no , street name, Area Name & District Name –

Confidential
 *City *Postal Code

*Prominent Landmark

*State *Country

*Period of Stay
From Date To Date
( DD/MM/YYY)

Door no , street name, Area Name & District Name –

*City *Postal Code

*State *Country

*Period of Stay
From Date To Date
( DD/MM/YYY)

Letter of Authorization from the Employee / Candidate

I hereby authorize (“NIIT Limited ”) or third party agency appointed by the Company to conduct
background verifications to validate the information I have provided to the Company including but not
limited to my employment, my personal background, professional standing, work history and
qualifications etc.

I authorize, without reservations, any individual, company or other private or public entity to furnish
to the Company or the third party agency appointed by the Company, all information about me

I release and hold harmless any individual, company, or private or public entity from any and all
causes of action that might arise from furnishing such information to the Company or the third party
agency appointed by the Company that they may request pursuant to this release.

This authorization and release, in original, faxed or photocopied form, shall be valid for this and any
future reference.

Signature

Confidential
 Name
(In Block Letters)

Date of Birth

Date

Confidential