3rd Floor, Cambata Building, Above Eros Theatre, Jamshedji Tata Road, Churchgate, Mumbai – 400020.
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Background Screening Form
CANDIDATE PERSONAL DETAILS
Applicant ID: IVS/MUM/
Full Name
Former Name(s) /
Maiden Name (If
applicable)
Father’s Name
Address 1: Current:
Address 2: Permanent:
Gender: Male Female Date of Birth: (DD/MM/YY)
Contact number
PAN Card number
3rd Floor, Cambata Building, Above Eros Theatre, Jamshedji Tata Road, Churchgate, Mumbai – 400020.
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EDUCATION HISTORY (Highest Qualification Onwards)
Board / Full time/ Seat / Roll/ Course Course
Exam
School/college University part time/ Registration Start End % Ach
Passed
and address affiliate to Distance number Date Date
Any other information you would like to provide (if any) : ______________________________________
Attention:
Please mention any details for re examination taken directly from the University or anything else you
would like to highlight.
Please mention if you have attained qualification with correspondence studies and also enclose copy
mark sheet with roll no. clearly indicated.
Please provide clear copy of the Final Year mark sheet / certificates for the education qualification
mentioned above.
EMPLOYMENT HISTORY 1 (Previous Employer)
Company Name :
3rd Floor, Cambata Building, Above Eros Theatre, Jamshedji Tata Road, Churchgate, Mumbai – 400020.
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Address (Main Office and Branch where worked):
Company Board Line Numbers (No Cell
Phone numbers accepted)
If Deputed by Agency - Agency name
and address
Tel no of the Agency
Employee Code
Designation and Dept
Date of Joining
Date of Leaving
Monthly Gross Salary
Reasons For leaving
Supervisor’s Name and Designation
Supervisor’s Official Mail ID
Supervisor's direct Line Number and
Mobile no.
Any other information you would like to provide:
Attention:
Please provide the Employee Code mandatorily and clearly
Please provide a copy of the last Salary Slip of your Current Employer
EMPLOYMENT HISTORY 2 (Previous Employer)
Company Name :
Address (Main Office and Branch where worked):
3rd Floor, Cambata Building, Above Eros Theatre, Jamshedji Tata Road, Churchgate, Mumbai – 400020.
[Link]
Company Board Line Numbers (No
Cell Phone numbers accepted)
If Deputed by Agency - Agency name
and address
Tel no of the Agency
Employee Code
Designation and Dept
Date of Joining
Date of Leaving
Monthly Gross Salary
Reasons For leaving
Supervisor’s Name and Designation
Supervisor’s Official Mail ID
Supervisor's direct Line Number and
Mobile no.
Any other information you would like to provide:
Attention:
Please provide the Employee Code mandatorily and clearly
Please provide a copy of the last Salary Slip of your Current Employer
Please provide a copy of your Relieving Letter / Service Certificate for Employment
mentioned above
PROFESSIONAL REFERENCE 1
Reference Name :
Reference Relationship with the Candidate
3rd Floor, Cambata Building, Above Eros Theatre, Jamshedji Tata Road, Churchgate, Mumbai – 400020.
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Reference Email ID:
Reference Mobile No:
Any other information you would like to provide:
PROFESSIONAL REFERENCE 2
Reference Name :
Reference Relationship with the Candidate:
Reference Email ID:
Reference Mobile No:
Any other information you would like to provide:
Letter of Authorization
To whom it may concern
I hereby authorize Integrity Verification Service Private Limited and any of its
representatives (IVS) to verify all the information provided in my application of
employment and to conduct such enquiries as may be required by IVS to verify facts of
3rd Floor, Cambata Building, Above Eros Theatre, Jamshedji Tata Road, Churchgate, Mumbai – 400020.
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such information provided by me. I hereby declare that this authorization shall be valid till
such time I remain an employee IVS
I hereby authorize all individuals, Private Establishments, Government
establishments/Agencies, Educational institutions who may have information relevant to
this enquiry to co-operate to IVS and/or its representatives such information as may be
required. I hereby release IVS, all its personnel and representatives from any liability
which could result, either directly or indirectly, from the disclosure of information by a third
party to another party in response to such enquiries.
Signature:
Name in Block Capitals
Date: