10 Jun 2019033136 PM

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Annexure – A3

GAIMS
Gujarat Adani Institute
of Medical Sciences

Employment Data Form

Please affix
recent passport
size photograph

Name:
(Surname) (First name) (Middle name)

Position applied for :

Department :

Location :

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A. Personal Data

1. Name:

2. Place of Birth: Date of Birth: ____________Age:________

3. Blood Group:

4. Present Address Permanent Address

5. Contact No: (M) ____ Office Resi.

6. E-mail Address:

7. PAN Number: Aadhar Card No.

8. Passport Number: Valid up to:

9. Nationality:

10. Domicile Details: State of Origin:


(Indian Nationals)
State of domicile: Since: yrs.

12. Identification Mark:

13. Religion:

14. Category: General ST SC OBC Other

15. Marital Status: Date of Marriage: __________________

16. Details of Family Members


Date
Sr. Name of Dependent
Name Relationship of Occupation
No. Employer YES / NO
Birth
1

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17. Languages Known: Mother Tongue:

Hindi English Regional / Vernacular / Other Pl. mention:

Read:
Speak:
Write:

18. Hobbies & Interests:

19. Please mention physical challenges, if any

B. Education and Training


1. Educational Record: (starting with SSC/ equivalent).Please mention “PT” for part-time and
“DL” for distance learning courses in the second column

Sr. Degree/Diploma Year of School/College No. of Duration Principal Percentage


No. Certificate Passing Board/University Attempts of course Subjects / Grade

2. Registration Details:

Sr. No. Degree Registration No. Council / State Valid till

3. Details of Research Publications:


State/National/ Year of Journal
Sr. Name of Papers
International Publica Journal Name Indexed
No. Published
Journals tion (Yes/No)

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4. Specialized Training / Certification/s:

Sr. Institute / Name of Course / Period


No. Organisation Certificate From To Subject(s)

5. Details of membership in professional bodies / institutions:

Sr. Institute / Type of


Remarks
No. Organization membership

C. Employment History

1. Total Experience: ________Years __________Months

2. Particulars of employment (starting from current employer):

Name & Location Period of Service Designation


Broad / Major
of employer From To Responsibilities
Initial Last
(dd/mm/y (dd/mm/y
y) y)

Please use additional sheets if required.


Please give your current remuneration details on the last page of this form.

2. Your present job responsibilities:

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3. Present organization structure:

Kindly circle your position and indicate your reporting relationship i.e. person to
whom you report and who reports to you.
D. General Information:

1. Significant achievements: distinctions/ honor/ awards received / Books

Year Details

2. What, according to you, are your strengths and areas for improvement?

Strengths:

Areas for improvement:

3. Reason for contemplating a change from the present job.

___________________________________________________________________________________

4. Reason for seeking appointment in the Adani Group

5. Any other information you would like to offer, including other / personal details /
Special achievements, if any
_

6. Are you prepared to relocate to any of our businesses / locations in India / Abroad?

Yes No

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7. Are you related to any employee / associate of Adani Group?

Yes No

If yes, give details below:

Name(s) : ____

Company /Business & Location: ____________________________________________________

Department: _______________________________________________________________________

Designation: _________________________________________

Nature of Relationship/Acquaintance: _____________

Note: Please furnish full details of all persons related or known to you. Attach/use
additional sheet if required.

8. Have you been interviewed by us / any of our group companies in the past?

Yes No

If yes, give below details

Position: ____________

Department / Function: _____________

Location: _____________

Company: __________________________________________________________________________

9. Pl give details of any illness / major surgery you may have suffered /
undergone during last 5 yrs., requiring hospitalization / prolonged treatment.

Period of Name & Address of


Nature of illness
hospitalization / treatment Hospital / Doctor

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10. References:

Please give references. (At least, one professional and one personal reference)

Name

Address

Occupation
Contact No.
E Mail

Self-Declaration

I _____________________________________________________ of age________ years and upwards, hereby


solemnly and sincerely declare as follows:
 I make this Declaration in relation to my interview / appointment in GAIMS
 I hereby declare that no convictions have been recorded against me, either within the
Republic of India or elsewhere.
 I also further declare that there have been no prosecutions, successful or not, pending or
completed, against me, either within the Republic of India or elsewhere.
 I hereby declare to the best of my knowledge and belief, there is nothing in relation to my
conduct, character or personal background of any nature that would adversely affect the
position of trust and confidence in which I would be placed.

 If any information is found to be suppressed, misrepresented or false, I shall be responsible


for the resultant consequences and shall render myself liable to disciplinary action
including termination of service without any compensation / notice.

Date: _______________________ Place: _____________ Signature: ____________________________________

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Current Remuneration details:
Please give details of your current remuneration in the first blank column:
Details Per Month Per Annum
Basic Salary
House Rent Allowance
Dearness Allowance
Conveyance Allowance
Fixed Children Education Allowance
Canteen Allowance
Other Allowance
Any Other
TOTAL (A) : Fixed
Petrol Expenses
Medical Reimbursement
LTA / LTC
Reimbursements
Any Other

Total (B): Reimbursements

PF (Employer Contribution)
Superannuation
Gratuity
Retirals
Any Other

TOTAL (C) : Retirals

Bonus / Ex-gratia
Performance Linked Incentive
Annual / Deferred
Payments Any Other
TOTAL (D) : Annual / Deferred
Payments
GRAND TOTAL

% Hike Expected

Expected CTC

Notice Period

Joining time required

Date: _______________________ Place: _____________ Signature: ____________________________________

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