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Background Verification Form

This document contains a background verification form requesting information to verify an applicant's identity and employment history. It requests personal details like name, date of birth, addresses, contact details, education and employment records. The applicant is also required to provide consent to release this information through an information release form. The purpose is to conduct employment background screening on the applicant.

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pranavpagar123
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257 views4 pages

Background Verification Form

This document contains a background verification form requesting information to verify an applicant's identity and employment history. It requests personal details like name, date of birth, addresses, contact details, education and employment records. The applicant is also required to provide consent to release this information through an information release form. The purpose is to conduct employment background screening on the applicant.

Uploaded by

pranavpagar123
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Background Verification Form

Reference No(Mandatory for BASS)

Name of Applicant

(Last, First, Middle)

Date of Joining Bajaj Allianz*

Employee Code

Maiden Name :

Have you ever been known by another YES NO


name?
If Yes, please write the other name:

Place of Birth: Date of Birth (dd/mm/yy):

Gender : Nationality:

Father’s Name: Passport No. SSN No.

(Mandatory for US address)

Home Phone Office Phone Mobile

RESIDENTIAL ADDRESS

Permanent Address

City : State :

Pin Code : **Nearest Landmark :

Name of the contact person at the address :

Relationship of contact person :

Landline No. Mobile No.

Nature Of Location: Rented/Owned/Others Preferred time of the day for conducting the verification, if
any :

Residing Since (Mandatory): Residing Till ( Mandatory):


EDUCATION RECORD

EDUCATION RECORD (Start with the latest/ highest qualification; please attach photocopies of the documents ) All
fields are mandatory

Name & Address of Name & Address of Type of Dates Attended Roll Number/
School/College/Institute University its affiliated Degree/Diplom Registration
a obtained. Number/Exam
State “F” for From To Seat number
fulltime and
“P” for part-
time within
brackets
EMPLOYMENT RECORD

If you are still employed in your current organization, please fill in the date before which you would not like the
verification to be initiated in the “To” column. If you are not sure or would like to intimate this date later, please
write 'Still Employed'

Employer 1 Employee ID From (mm/yy) To (mm/yy)

Full Name

Address Phone Number

City State Country Postal Code

Permanent (onrolls) or temporary (contractual)

Agency Details (if temporary/contractual)

Job Title Reason of Leaving

Designation Final Salary (Annual CTC)

Supervisor Name & Title HR Manager Name

Supervisor ‘s Phone Number HR Manager Phone Number

Verified by:

Sign: _______________________

Name in Block Capitals:______________________

Date: ________________________
Information Release Form

To Whom It May Concern:

Please print

I_______________________________________________________________________
Last name First name Middle name

I hereby authorize my current/prospective employer and/or or their authorized representatives and contractors to verify
information presented on my employment application/resume and to procure an investigative report or consumer report
for that purpose.

I hereby grant authority for the bearer of this letter to access or be provided with full details

of my previous employment record held by any company or business for whom I previously worked. This
information should include the dates of employment; the nature of the position held, [details of my salary upon
departure] and an appraisal of my performance, capabilities and character. In addition, please provide any
other pertinent information requested by the individual presenting this authority. I hereby release from liability
all persons or entities requesting or supplying such information.

of my qualification/degree (copy of my certificates attached)

information in respect to my character from the records maintained by local authorities

Signature: Date: dd / mm / yyyy

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