Employment Form

MANSURI RIZWAN SHAKIL

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

Position applied for : DGM

Name of the Company : Portus Venture Pvt Ltd

Function : CSD

Location : Mumbai

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 A. Personal data

1. Name: Rizwan S Mansuri

2. Have you ever been known by another name? _____________________NA______________

3. Place of Birth: Rajasthan______________ Date of Birth: _30th April 1983_________________

4. Blood Group: B+
5.
Current Address__Saroopi Gulshan Flat no 304, Building 8, Naya Nagar
__________________________________________________________________________

City :_Mira Road _____________________ State : ____Maharashtra____

Pin : _401107__________________ Nearest Landmark : _Janta Dairy_______
Contact Person at the address :____Shakil Mansuri________________________________
Relationship of contact person : ___ Father_________________________________
Landline No._________NA________________ Mobile No.__9820722828_______
Nature Of Location: Rented/Owned/Others Preferred time of the day for conducting the
verification, if any : _________Anytime______
___________Owned_________________
Residing Since (Mandatory):____25 years___ Residing Till ( Mandatory):_____Building
collapse ___

RESIDENTIAL ADDRESS
Permanent Address______________Same as Above_____________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
City : ____________________________ State : ______________________________
Pin : _____________________________ Nearest Landmark : ___________________
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):______________

6. Father’s Name: __________Shakil Mansuri ______________________________________

7. Telephone No: (M)__9867864513_ Landline: Office_____________ Resi._______________

8. E-mail Address: [email protected]_________________________________

9. Permanent Account Number: ____________________________________________________

10. Passport Number: _________X3809853_______ Valid up to: ___________18/02/2034______

11. Nationality: _______________Indian_______________________________________________

12. Domicile Details: State of origin: _____________________

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

12. Identification Mark: ___________________________________________________________

13. Religion: ________Islam_____________________________________________________

14. Category: ________OBC___ General ST SC OBC Other

15. Marital Status: ________YES___________ Marriage Date: : _________28th April 2008________

16. Details of family members

Date Of Name Of Dependent

Sr. Name Relationshi Birth Occupatio Employer Yes / No
No. p n
1 SHAKIL MANSURI FATHER RETIER NA YES
2 FEMIDA MANSURI MOTHER HOUSEWIFE NA YES
3 YASMIN MANSURI SPOUCE HOUSEWIFE NA YES
4 ALIYA MANSURI DAUGHTER STUDENT NA YES
5 MASHEERA MANSURI DAUGHTER STUDENT NA YES
6 REHAN MANSURI SON STUDENT NA YES

17. Languages Known: Mother Tongue: Hindi

Regional / Vernacular / Other

Hindi English Pl. mention:

________ ________ ________

Read:

Speak:

Write:

18. Hobbies & Interests: __________________________________________________

19. Extra-curricular activities: _____________________________________________

20. Please mention physical challenges, if any ________________________________

B. EMPLOYMENT DATA

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

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 Period of Name and Name, Title
Service Contact of and
CTC Emp
Name & Location of From To Designation HR Contact of
PA Code
employer (dd/mm/ (dd/mm/ Manager Supervisor
yy) yy)

Please use additional sheets if required.

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

2. Your present job responsibilities:

_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
___________________________

3. Present organization information:

REPORTING TO:

NO. OF REPORTEES:

C. 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
Degree/Diploma Year of School/College No. of Duration Principal Percentag Roll No.
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 Certificate Passing Board/University Attempts of Subjects e/ Grade
course

2. Specialized Training / Certification/s:

Sr. Institute / Name of Course / Period Subject(s) Percenta

No. Organisation Certificate From To ge/
Grade

3. Details of membership in professional bodies / institutions:

Sr.N Institute / Type of Remarks

o. Organization membership

D. General Information:

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

Year Details

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

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Strengths:

Areas for improvement:

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

4. Reason for seeking appointment in Portus Ventures

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

8. Have you been interviewed by us 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.

Nature of illness Period of Name & Address of

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 hospitalization / treatment Hospital / Doctor

10. References:

Please give references of at least three persons who are not your relatives / friends.
(at least, one professional and personal reference)

Name
Address

Occupation:
Mobile / Office Tel.
E Mail
Tel. No. (Resi.)

I hereby declare that the information and details furnished herein are true and complete to the best of
my knowledge and belief. 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.

Place: __________________ Date: _________________ Signature: _________________

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Current Remuneration details:

Please give details of your current remuneration in the column/s titled “Currrent Remuneration”:

Details Current Remuneration

p.m p.a.
Fixed
Benefits
Retrials
Bonus/ Variable / PLI
Grand Total (A+B+C+D)

Compensation Expected (Cost To Company): Rs. ___________________ (Per annum)

Joining time required: ___________________________

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Information Release Form:

To Whom It May Concern:

I_______________________________________________________________________
Last name First name Middle name

I hereby authorize ____________________ (name of the company) or their representatives to verify

information presented by me through this form 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
n 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.
n of my qualification/degree (copy of my certificates attached)
n information in respect to my character from the records maintained by local authorities

Signature: Date: dd / mm / yyyy

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