Employment Application Form

Important
1. Please read the contents of this form
thoroughly before filling it.
2. Form needs to be filled completely
before submitting. If space is
insufficient, use a separate sheet.
Incomplete forms will be rejected.
3. Any declaration, if found to be untrue or
found to be concealing facts, will result
in immediate
disqualification/termination or legal
action.
Post applied for: …………………………………………Location………………………

How did you come to know about this position (Pease specify source):

……………………………………………………………………………………………………………

If through Manpower Recruitment Consultant, pls specify name of the consultant:

…………………………………………………………………………………………

……………………………………………………………………………………………………………

I. Personal Data Record

Full Name: ……………………………………………………………………………………………….

(IN CAPITAL RECENT
LETTERS) ………………………………………………………………………………………………. PHOTO, not older than 6
months
Short name used in routine communication ……………………………………………………… (Mandatory)

E-Mail: ……………………………………………………………………………………………………………….

Mobile: ………………………………………………………………………………………………………………

Emergency contact (Mobile): …………………………………………………………………………….

Present Address: ……………………………………………………………. Permanent Address: ……………………………………………………….

……………………………………………………………………………………….. ………………………………………………………………………………………..

……………………………………………………………………………………….. ………………………………………………………………………………………..
……………………………………………………………………………………….. ………………………………………………………………………………………..

Pin Code: ……………………………………………………………………….. Pin Code: ………………………………………………………………………..

Residence (Phone): ………………………………………………………. Residence (Phone): ………………………………………………………..

Other Particulars:

Date of Birth: ………………………………….. Place of Birth: …………………………………. Nationality: ……………………………………………

Religion: …………………………………………. Marital Status (Single/ Married/ Divorced/ Widowed):……………………………………..

If divorced, pls specify for how long and no. of dependent children: ……………………………………………………………………

Blood Group: ………………………………….. Height: ……………………… (……...’…..….”) Weight (Kgs): …………………………………..

Aadhaar No.: …………………………………………… P.F. No. (If Any): ……………………………… ESI No: ………………………………………….

PAN No: …………………………………………. Passport No.:……………………………………….

Final Certificate for COVID-19 Vaccination received (Yes/No): ………………………

(Application will be processed only if 14 days completed after 2nd dose)

Do you have any physical disability? If yes, give details:

……………………………………………………………………………………………………………………………………………………………………………………

……………………………………………………………………………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………………………………………………………………………….

Do you have any medical sickness now or in past for which you are undergoing therapy or medication? If yes, give
details:

……………………………………………………………………………………………………………………………………………………………………………………

……………………………………………………………………………………………………………………………………………………………………………………

……………………………………………………………………………………………………………………………………………………………………………………

II. Details of Family

Name Age Occupation /Company
Husband/Wife
Children 1.
2.
Father
Mother
Brothers 1.
 2.
Sisters
1.
2.

Please mention any family member working in Shipping/ Logistics/ Freight Forwarding/ Port/ Govt. Service etc.
(provide complete details)

……………………………………………………………………………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………………………………………………………………………..

III. Education and Training

Place Period Degree / Diploma Major Subjects

School/ College Attended Class / Grade
Attended From To Obtained Studied

IV. Short-term & Part-time Specialized Courses/Training Programmes Attended

Institution Place Year Duration Course Duration Certificate Awarded

Do you possess any specific skills suited to the job you have applied for? Give Details:

……………………………………………………………………………………………………………………………………………………………………………………..

……………………………………………………………………………………………………………………………………………………………………………………..

V. Work Experience

Tenure Salary on Salary on Leaving

Leaving Basic / Total
In From To Reason for
Employer’s Name and Address Basic / Total Annual Gross
Years Leaving
Monthly (excluding ex-
gratia, bonus etc)
Present (1)

Previous (2)

Previous (3)

Previous (4)

Immediate Superior’s Email &

S. No. Designation and Job Description under each employer as above*
Name & Designation Contact No

1.

2.

3.

4.

*If space is insufficient, please attach a separate sheet.

VI. If any break in working experience for more than 30 days, specify reason for breaks & gaps

……………………………………………………………………………………………………………………………………………………………………………………..

……………………………………………………………………………………………………………………………………………………………………………………..

VII. Hobbies and Pastimes; Computer / Web Literacy

……………………………………………………………………………………………………………………………………………………………………………………..

VIII. Languages Known

Language Speak Read Write

(Mother Tongue)
Pls specify

IX. Have you been previously interviewed in Samsara or any of our Group Companies?
 Yes No

When (Date): ................................. For (Dept./Location): ................................. Interviewed By: .................................

X. Have you previously worked in Samsara or any of our Group Companies?

Yes No

When (Tenure From – To): ................................................ For (Dept./Location): .........................................................

Reason for leaving: ......................................................................................................................................................

………………………………………………………………………………………………………………………………………………………………………………..

XI.. References
ii1
List two responsible people, not related to you, who can comment objectively on your career and capabilities:

1. Name: ……………………………………………………………………………………………………………………………………………………………………

Company: ………………………………………………………………….. Designation/Occupation: ……………………………………………..

Address: ………………………………………………………………………………………………………………………………………………………………..

…………………………………………………………………………………… Email: …………………………………………………………………………..

Phone: ………………………………………………………………………. Period for which known: ………………………………………………..

Capacity in which known……………………………………………

2. Name: ……………………………………………………………………………………………………………………………………………………………………

Company: ………………………………………………………………….. Designation/Occupation: ……………………………………………..

Address: ………………………………………………………………………………………………………………………………………………………………..

…………………………………………………………………………………… Email: …………………………………………………………………………..

Phone: ………………………………………………………………………. Period for which known: ……………………………………………….

Capacity in which known……………………………………………..

XII Expected Salary (unacceptable expectation will be invalidated, Management reserves the rights to
decide the final offer)

Last drawn Salary (Monthly): …………………………… Expected Salary (Monthly): ………………………………………

Percentage Increase: ………………………………………..

Pls justify reasons for the expectation and how will you contribute/add value to the company and guarantee
efficiency in return: …………………………………………………………………………………………………………………………………………………….

…………………………………………………………………………………………………………………………………………………………………………………….

…………………………………………………………………………………………………………………………………………………………………………………….
Joining date, if selected (Must be between 15-30 days from the date of final interview): …………………………………………..
Note to HR: Offer letter must be issued within 3 working days from the date of final interview and selection.

XIII. Is any employee of Samsara Group known or related to you? If yes, please give details:
Name: ………………………………………………………………………………………………………………………………………………………………………….

Designation: …………………………………………………………………… Location: ………………………………………………………………………

Company: ………………………………………………………………………. Relationship: ………………………………………………………………….

XIV. Declaration :

1. I agree to undergo a medical check-up, at my own cost, from the company empanelled Medical Centres as
suggested by the company prior on boarding.

2. The company reserves the right to transfer me anywhere in India, if necessary, in the interest of the company’s
business/individual growth and/or as a part of the employment contract and also terminate services in case of
refusal to get transferred in the interest of the company.

3. I certify that the information provided above is correct and complete. If at any time, I am found to have
concealed any material information or given any false details, my appointment shall be liable to summary
termination without notice or compensation in lieu thereof, including legal action for misdeclaration.

4. I certify that the company can anytime, before my joining and after issue of offer letter cancel my candidature if
found that I have concealed my medical history or provided any medical misinformation in Employment
Application Form.

5. I hereby authorize the Company and its appointed agencies, to verify information provided in my resume,
Samsara Employment Application Form and other relevant documents submitted by me for the purpose of
employment. I agree and provide my consent for any verification process and will also request anyone
concerned to facilitate and/or disclose the relevant data to complete the verification process.

Date: ............................................. Place: ……………………………………… Signature: ………………………………………

XV. List of Mandatory Documents to be attached along with the Application Form:

1. Final Certificate for COVID-19 Vaccination

2. Last three month’s Salary Slip
3. Bank Statements for the months supporting the salary slip
4. Appointment letter of current Employer and previous employers
5. Latest Increment letter
6. Relieving / Experience letter of all previous employments
7. Education Mark sheet of SSC, HSC, Graduation, Post-Graduation and Professional Degree
8. Passport (1st & last page)
9. PAN Card
10. Aadhaar Card
11. Latest Form 16
 12. EPFO Passbook
13. Passport size photo with white background (for men, photo required with tie and white background)
14. Medical Documents for any physical disability or medical sickness for which you are undergoing
treatment/medicines.

Note: All of the above documents are mandatory to be submitted along with the Application form. Application
will NOT be processed further, if any of the required documents are missing.
===============================================================================================
For office use only:
Documents Processed By: Documents Checked By:
Name of HR Representative: Name of HR Head:
Date: Date:
Signature: Signature: