BACKGROUND VERIFICATION FORM

Instructions: Please fill the form in BLOCK letters only and do not use any
abbreviations

Personal Information
First Name Tanish
Middle Name
Last Name Kumar
Nationality Indian
Gender Male Female Transgender Others
Marital Status Single
Contact Number +919205836128
Email ID [email protected]

Date of Birth 0 8 0 8 1 9 9 7
Father’s Name Shri Sanjay
Identification Number 9982 8105 6962
Identification Type Mole on right ankle

Note – It is mandatory to provide PAN Card & Aadhar Card as Identity Proof

Current Address
House/Flat Number House number 429
Building Number & Name
Address Line 1 Sadarpur colony
Address Line 2 Sector 45
Address Line 3
City Noida
Postal Code 201303
State Uttar Pradesh
Country India
Prominent Landmark Near RK public school
From 0 8 0 8 1 9 9 7
Period of Stay
To T I L L D A T E
Contact Number 9205836128
Note – It is mandatory to provide Address Proof (Aadhar / Driving License / Electric Bill – Not Older Than 3 Months)

CONFIDENTIAL
 Permanent Address
Same As Above Yes No
House/Flat Number
Building Number & Name
Address Line 1
Address Line 2
Address Line 3
City
Postal Code
State
Country
Prominent Landmark
From D D M M Y Y Y Y
Period of Stay
To D D M M Y Y Y Y
Contact Number
Note – It is mandatory to provide Address Proof (Aadhar / Driving License / Electric Bill – Not Older Than 3 Months)

Previous Address
Same As Above Yes No
House/Flat Number
Building Number & Name
Address Line 1
Address Line 2
Address Line 3
City
Postal Code
State
Country
Prominent Landmark
From D D M M Y Y Y Y
Period of Stay
To D D M M Y Y Y Y
Contact Number
Note – It is mandatory to provide Address Proof (Aadhar / Driving License / Electric Bill – Not Older Than 3 Months)

CONFIDENTIAL
 EDUCATION SECTION
SSC / 10th / Equivalent
Name of Qualification Obtained Secondary school certificate

Area of Specialization (s) Science

Institution Name and Contact Details RSS inter college

(School/ College/Institute)

Name & Address of University / Board Board Of High School & Intermediate Education, Uttar Pradesh

Enrolment / Roll / Registration Number

From 0 5 1 0
Period of Study
To 0 5 1 1

2011
Year of Passing Course Completed Yes No Pursuing

Course Attended Regular Evening Correspondence

Note – It is mandatory to provide SSC Marksheet / Diploma Certificate

HSC / 12th / Pre – University / Equivalent

Name of Qualification Obtained Senior secondary school certificate

Area of Specialization (s) Science

Institution Name and Contact Details RSS inter college

(School/ College/Institute)

Name & Address of University / Board Board Of High School & Intermediate Education, Uttar Pradesh

Enrolment / Roll / Registration Number

From 0 5 1 2
Period of Study
To 0 5 1 3

2013
Year of Passing Course Completed Yes No Pursuing

Course Attended Regular Evening Correspondence

Note – It is mandatory to provide –

* In case of HSC – Marksheet / Diploma Certificate
* In case of Technical Diploma / ITI – Final Year Marksheets + Level Marksheet + Diploma / ITI Certificate

CONFIDENTIAL
 Graduation

Name of Qualification Obtained Bachelor of science

Area of Specialization (s) Physics

Institution Name and Contact Details shri ravinath singh degree college

(School/ College/Institute)

Name & Address of University / Board Chhatrapati Shahu Ji Maharaj University, Kalyanpur, Kanpur, Uttar
Pradesh 208012
Enrolment / Roll / Registration Number

From 0 5 1 5
Period of Study
To 0 5 1 8

Year of Passing 2018 Graduated Yes No Pursuing

Course Attended Regular Evening Correspondence

Note – It is mandatory to provide Final Year Marksheets + Degree Certificate / Provisional Degree Certificate

Post – Graduation or Professional Certification

Name of Qualification Obtained

Area of Specialization (s)

Institution Name and Contact Details

(School/ College/Institute)

Name & Address of University / Board

Enrolment / Roll / Registration Number

From M M Y Y
Period of Study
To M M Y Y

Year of Passing Graduated Yes No Pursuing

Course Attended Regular Evening Correspondence

Note – It is mandatory to provide Final Year Marksheets + Degree Certificate / Provisional Degree Certificate

CONFIDENTIAL
 EMPLOYMENT SECTION

Note: Please start with your most recent employer

Employer 1
Company Name Progressive info vision India private limited

Address Line 1 RWA Colony

Address Line 2 Janakpuri

Address Line 3

City New Delhi

Postal Code 110058

State Delhi

Company Phone No. 011 4740 4740 Company Website

Designation Desktop support engineer L2 Supervisor Name Ankit Kumar

Department IT Supervisor’s Designation Team Lead

Remuneration (CTC - PA) 3.44 LPA Supervisor’s Email ID [email protected]

Employee ID PIPLM15169 Supervisor’s Phone No. 6207402613

HR’s Email ID [email protected]

HR’s Contact Number 9873036593

Date of Joining 1 9 0 4 2 4

Date of Exit 3 1 0 1 2 5

SSN / Employee / ID Code PIPLM15169 Reason for Leaving Career Growth

Employment Type Full – Time Part – Time

Nature of Employment Probation Permanent Contractual Temporary

Outsourcing Agency Details, if through contract

Note – It is mandatory to provide Relieving Letter + Experience Letter + Recent Salary Slip before relieved

CONFIDENTIAL
 Employer 2
Company Name Agreeya solutions

Address Line 1 Airtel Building

Address Line 2 B-38C/2

Address Line 3 Sector 57

City Noida

Postal Code 201301

State Uttar Pradesh

Company Phone No. 120 439 4444 Company Website

Designation Desktop support engineer Supervisor Name Kushank Singh

Department IT Supervisor’s Designation Lead-IT

Remuneration (CTC - PA) 3.85 LPA Supervisor’s Email ID

Employee ID IN-12633 Supervisor’s Phone No. 8218250408

HR’s Email ID HR.agreeya.com

HR’s Contact Number

Date of Joining 0 8 0 5 2 3

Date of Exit 2 9 0 1 2 4

SSN / Employee / ID Code IN-12633 Reason for Leaving Career Growth

Employment Type Full – Time Part – Time

Nature of Employment Probation Permanent Contractual Temporary

Outsourcing Agency Details, if through contract

Note – It is mandatory to provide Relieving Letter + Experience Letter + Recent Salary Slip before relieved

CONFIDENTIAL
 Employer 3
Company Name Netrika consulting

Address Line 1 Near Shiv Mandir

Address Line 2 Shalimar Bagh

Address Line 3

City New Delhi

Postal Code 110088

State Delhi

Company Phone No. 121 300 000 Company Website

Designation Desktop Support Engineer Supervisor Name Aasim Raza

Department IT Supervisor’s Designation Manager

Remuneration (CTC - PA) 3.10 LPA Supervisor’s Email ID

Employee ID N-690 Supervisor’s Phone No. 7078131920

HR’s Email ID

HR’s Contact Number

Date of Joining 1 3 0 2 2 3

Date of Exit 0 4 0 5 2 3

SSN / Employee / ID Code N-690 Reason for Leaving

Employment Type Full – Time Part – Time

Nature of Employment Probation Permanent Contractual Temporary

Outsourcing Agency Details, if through contract

Note – It is mandatory to provide Relieving Letter + Experience Letter + Recent Salary Slip before relieved

CONFIDENTIAL
 Employer 4
Company Name Hello verify India private limited

Address Line 1 Berger Tower

Address Line 2 Sector 16B

Address Line 3

City Noida

Postal Code 201301

State Uttar Pradesh

Company Phone No. 92896 27622 Company Website

Designation Executive Supervisor Name Sudhanshu Negi

Department IT Supervisor’s Designation Manager

Remuneration (CTC - PA) 3.22 LPA Supervisor’s Email ID

Employee ID 999815 Supervisor’s Phone No. 9627275036

HR’s Email ID [email protected]

HR’s Contact Number 8512051340

Date of Joining 2 4 0 3 2 1

Date of Exit 0 4 0 2 2 3

SSN / Employee / ID Code 999815 Reason for Leaving

Employment Type Full – Time Part – Time

Nature of Employment Probation Permanent Contractual Temporary

Outsourcing Agency Details, if through contract

Note – It is mandatory to provide Relieving Letter + Experience Letter + Recent Salary Slip before relieved

CONFIDENTIAL
 Employer 5
Company Name M/s adroit technical services India private limited

Address Line 1 Mayur Vihar Phase II

Address Line 2 Mayur Vihar

Address Line 3

City New Delhi

Postal Code 110091

State Delhi

Company Phone No. 0120 481 7444 Company Website

Designation Executive Supervisor Name Deepak Kumar Sharma

Department Real estate Supervisor’s Designation

Remuneration (CTC - PA) 15k in hand Supervisor’s Email ID 7011458373

Employee ID Supervisor’s Phone No.

HR’s Email ID

HR’s Contact Number

Date of Joining 0 2 0 2 2 1

Date of Exit 2 1 0 3 2 1

SSN / Employee / ID Code Reason for Leaving

Employment Type Full – Time Part – Time

Nature of Employment Probation Permanent Contractual Temporary

Outsourcing Agency Details, if through contract

Note – It is mandatory to provide Relieving Letter + Experience Letter + Recent Salary Slip before relieved

CONFIDENTIAL
 Additional Employers
Company Name Hello verify India private limited

Address Line 1 Berger Tower

Address Line 2 Sector 16B

Address Line 3

City Noida

Postal Code 201301

State Uttar Pradesh

Company Phone No. 92896 27622 Company Website

Designation Executive Supervisor Name Sudhanshu Negi

Department IT Supervisor’s Designation

Remuneration (CTC - PA) 2LPA Supervisor’s Email ID

Employee ID 999282 Supervisor’s Phone No. 9627275036

HR’s Email ID [email protected]

HR’s Contact Number 8512051340

Date of Joining 1 6 0 4 1 9

Date of Exit 1 0 1 1 2 0

SSN / Employee / ID Code 999282 Reason for Leaving

Employment Type Full – Time Part – Time

Nature of Employment Probation Permanent Contractual Temporary

Outsourcing Agency Details, if through contract

Note – It is mandatory to provide Relieving Letter + Experience Letter + Recent Salary Slip before relieved

CONFIDENTIAL
 Professional Reference Information

Details Mandatory Reference 1 Reference 2 Reference 3

Sudhanshu Negi Rahul kumar Vijay Patel
Name

Manager-IT Assist manager-HR

Designation

Organization

Colleague Colleague Colleague

Relationship

9627275036 8512051340 8574150004

Telephone Number

Email ID

Required Professional References only (e.g., Professors, Principal, Reporting Managers, Directors,
etc.).
Blood Relations, Relatives, Friends are not allowed to enter.

CONFIDENTIAL
 Letter of Authorization
To Whomsoever it May Concern

I understand that the information provided by me may be used by the organization or an outside

agency on behalf of employer to verify and validate the information I have provided including my

employment, my personal background, professional standing, work history, and qualifications.

I understand that the organization or an outside background agency may obtain the information it

deems appropriate from various sources including, but not limited to, the following: current and

past employers, criminal conviction records, school records, College records, and professional and

personal references.

I authorize, without reservation, any individual, corporation, or other private or public entity to

furnish the organization or outside background verification agency all information about me.

I unconditionally release and hold harmless any individual, corporation, or private or public entity

from any and all causes of action that might arise from furnishing to the organization or outside

background verification agency that they may request pursuant to this release.

This authorization and release, in original, faxed or photocopied form shall be valid for this and

any future reports and updates that may be requested.

Thanking You,

Name – Tanish kumar

Signature -

Date- 02 Jan 2025

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