EMPLOYEE BACKGROUND VERIFICATION FORM

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 CAPTIAL LETTERS.
The details on this form will be used for all official requirements should you join the organization.

Position applied for Employee Code Location

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 UAN (12 Digit) 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

Previous Address 1 Period of From (mm/yy) To (mm/yy) Residence Number

stay

Pincode
Prominent Landmark Mobile number

Previous Address 2 Period of From (mm/yy) To (mm/yy) Residence Number

stay

Pincode
Prominent Landmark Mobile number

Previous Address 3 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
 College Name & Address University Name & Address Dates Attended Qualification ID /Roll No
From To Gained
dd/mm/yy dd/mm/yy

Full Time
Part Time

College Name & Address University Name & Address Dates Attended Qualification ID /Roll No
From To Gained
dd/mm/yy dd/mm/yy

Full Time
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/ Last Employment

Name of Current/ Last 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

From To now?
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)

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

Note:-Kindly share supporting document for the gap period

Documents Required (Mandatory)

Education:
Photocopy of degree certificate and final mark sheet of all examinations

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

Identity
Pan Card / Passport Copy/ Driving License

Declaration and Authorization

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: