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Background Verification Form

This document is a background verification form for Omega Healthcare Management Services Pvt. Ltd. It requests personal details such as name, date of birth, address, education history, and employment history from the applicant. The applicant is also asked to provide authorization for Omega Healthcare to conduct reference checks and background verification on the information provided. The verification process may involve police authorities directly contacting or visiting the applicant's current and permanent addresses listed to complete their standard verification procedure.

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khallushaik424
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158 views

Background Verification Form

This document is a background verification form for Omega Healthcare Management Services Pvt. Ltd. It requests personal details such as name, date of birth, address, education history, and employment history from the applicant. The applicant is also asked to provide authorization for Omega Healthcare to conduct reference checks and background verification on the information provided. The verification process may involve police authorities directly contacting or visiting the applicant's current and permanent addresses listed to complete their standard verification procedure.

Uploaded by

khallushaik424
Copyright
© © All Rights Reserved
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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Omega Healthcare Management Services Pvt. Ltd.

BACKGROUND VERIFICATION FORM

Attach recent passport


sized photograph

Personal Details

Full Name: Male /Female Marital Status: Single/ Married


Date of Birth: Nationality: Father’s name:
Employee No: Designation:
Place of joining: Date of Joining:
Current Residential Address:

Period of stay at current address: From: To:


Telephone (Home): Mobile:
Email address:

Permanent address:

Period of stay: From: To:


Telephone: Mobile:

Doc. Ref : OMH-FOR-HRD-004-V1.0 1


Educational qualification: (Highest Degree)

(Important: Copy of Mark sheet and Degree certificate MUST be attached)

College name

College Address

University Name and address

From – To Graduated Program Student ID/ Enrolment No


(Month / Year)
Yes / No Full time /Part
time/ Day /
evening
Type of degree Graduation date Major Subject

Employment History – (Relieving letter copy to be attached till last but one employer)

Details of Current or last Employer

Company Position Held&


Name: Dept
Address( Main office & Branch where Telephone
worked)

Employment date: ( Date, Month , Year) Employee code:

From: To:

Whether employment is temporary or permanent in Nature - Temp Permanent

Agency details ( If temporary or Contractual)

Responsibilities:

Remuneration: Reason for leaving:

Reported to: name, Position & Contact


No

Doc. Ref : OMH-FOR-HRD-004-V1.0 2


Details of second last Employer

Company Position Held&


Name: Dept
Address( Main office & Branch where Telephone
worked)

Employment date: ( Date, Month , Year) Employee code:

From: To:

Whether employment is temporary or permanent in Nature - Temp Permanent

Agency details ( If temporary or Contractual)

Responsibilities:

Remuneration: Reason for leaving:

Reported to: name, Position & Contact


No

Can reference check be done: Yes / No


Name and contact details of 2 referees 1.

2.

Doc. Ref : OMH-FOR-HRD-004-V1.0 3


Letter of Authorisation:

To whomsoever it may concern

I hereby authorize Omega Healthcare Management Services Pvt. Ltd. and its authorized
representatives to verify information provided in my resume and application of employment, and to
conduct enquiries as may be necessary, at the company’s discretion. I authorize all persons who may
have information relevant to this enquiry to disclose it to Omega Healthcare Management Services
Pvt. Ltd. or its representative. I release all persons from liability on account of such disclosure.

I hereby authorize concerned authorities to dispatch my confidential report to Omega Healthcare


Management Services Pvt. Ltd or its authorized representative.

Signed: ---------------------------------------------------

Name: ------------------------------------------------------

Date: -----------------------------------------------------------

** As is the procedure followed by most police departments across India for criminal back ground
verification, it is possible that police authorities may contact or visit the stated residence and at times
even ask to be physically present at the concerned police station. It is part of the standard verification
procedure.

Doc. Ref : OMH-FOR-HRD-004-V1.0 4

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