Employee Self Verification Form

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Content

Applicant No/ Employee ID RAS-AP-193 GUNTUR

Location

Date of Joining/Interview 16-12-2010

Please provide complete and correct information. All fields are mandatory. Please do not use short forms / abbreviations.
Personal Details Full Name (First, Middle, Last) SHAIK Khudavan Former Name(s) / Maiden Name (if applicable) Gender:  Male  Female Date of Birth (dd/mm/yy) 12-06-1989 Remarks If Any

Father’s Name Mother’s Name Wife’s/Husband’s Name (If applicable) Other Family Members Name. Relation Residence No

Shaik.Khasimpeera Madarbi no

Shaik mastanvali Brother Mobile No 9704820426 Mobile no. of family member 8008530115

Complete Address Building/Apt. Name: Current Address H.No/D.No/Flat No: 4-115 Street/ Colony Name: Location: Gottipadu Landmark: Near Urdu School City: Guntur Pin code: 5220019 Own House/ Rented :: Own House owner Phone No. and Name – Complete Address

Permanent Address

Building/Apt. Name : H.No/D.No/Flat No : Street/ Colony/Village Name : Location: Landmark: City: Pin code: Gram Panchayat Head Name :: Ph. No. ------------ DO -------------

Complete Address of any Family Members Current Address Building/Apt. Name: H.No/D.No/Flat No: Street/ Colony / Village Name: Location: Landmark: City: Pin code: -------------- DO -------------------

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Education Qualification
Educational Record (1) - Highest Qualification (Please attach copy of degree certificate and final year mark sheet.) College Name (Full) Hindu College Guntur School Name (Full) Z.P.H School Location Gottipadu University Name (Full) Location Location

School/College Address (Full address with City and Pin code)

Hindu College, Guntur, Beside Guntur Market.

University Name and Address

From (month / year)

To (month / year)

Graduated  Yes  No

Program  Full Time  Part Time

Roll No / Enrollment No.

Type of degree/qualification

Graduation date (month / year)

Subject Major

Copy of Certificate Attached

 Yes

 No

i. Character Certificate
ii. Address Certificate

Mukhiya / Sarpanch / SDO Court (Issued within Six month) Voter Identity / Rashan Card / Residential Certificate

Final Year Mark sheet Attached

 Yes

 No

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Employment Section
Ensure that you are descriptive wherever necessary – e.g. If Co. is closed, do mention it. Employee Code/ ID/ Number are mandatory. If your last employer did not provide one, please mention and state reasons for the same.
Details of Last Employer
Please attach a copy of your last Pay slip & relieving letter/service certificate/Resignation acceptance on letter head Company Name (1) : Prithvi Informationsolutions ltd Last Designation Rigger Department O&M

Address(worked) Hyderabad

Address (Corporate Office Prithvi house, #2-56/2/19, Khanamet, Madhapur, Hyderabad.

Office Telephone (where worked) 040 44856019

Office Telephone (Corporate Office) 040 44856019

Employment Period: (date, month, year) From 01-11-2010 To 15-12-2010

Employee Code/ Personnel No:

Remunerations (Gross Salary/month or P.A) 8500/PM

REPORTING MANAGER DETAILS (Mandatory) Name: Seshagiri Rao Designation: : Asst vp Department Contact No

Email ID of Reporting Manager: HUMAN RESOURCES MANAGER DETAILS (Mandatory) Name: Praveena Designation: HR Contact No ((Mandatory)

Email ID of HR Manager (IF AVAILABLE): Reason(s) for Leaving Contract changed

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Details of Previous Employer
Please attach a copy of your last Pay slip & relieving letter/service certificate/Resignation acceptance on letter head Company Name (2) Last Designation Department

Address (where worked):

Address (Corporate Office)

Office Telephone (where worked)

Office Telephone (Corporate Office)

Employment Period: (date, month, year) From To

Employee Code/ Personnel No:

Remunerations (Gross Salary/month or P.A)

REPORTING MANAGER DETAILS (Mandatory) Name: Designation: Email ID of Reporting Manager: HUMAN RESOURCES MANAGER DETAILS (Mandatory) Name: Designation: Contact No ((Mandatory) Department: Contact No

Email ID of HR Manager (IF AVAILABLE): Reason(s) for Leaving

Page 5 of 6

Self Declaration and Authorization
I understand that any employment by ____Company Name____ or its affiliated companies is conditioned upon positive responses from my references, bonding eligibility, continued adherence to ____________________ policies and procedures, applicable rules and regulations and job performance satisfactory at all times to ____________________. I consent to take any pre or post-employment examinations and or verification/checks as may be required by ____________________ or its representative. I further authorize ____________________ to make inquiries by written communication, by telephone, or in persons to any former employer, government, agency, educational institution, state police or any other regulatory, compliance body or organization or any other persons or institutions knowledgeable of my background, prior history, work experience, nature of duties, CTC, performance levels, reliability, responsibility, honesty and any other measures of my character or personality. I release ____________________ from any liability that may arise from such examination and/or verification/checks. Former employers and officials of education institutes, named on this application are authorized to give information about me and I release them from all liability for issuing such information. I hereby attest and warrant that all my answers on this application as well as on all forms completed in conjunction with my employment are true and accurate. I understand that my misrepresentation of facts, failure to disclose information required on this application or material change in my information provided which is not reported to Human Resources shall be cause for dismissal regardless of when discovered by ____________________. A Photostat or any other copy of this instrument bearing my signature shall be equally legally valid as the original

Signature FULL Name (In Block Letters) SHAIK. Khudavan Date 25-07-2012 Place Guntur

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