1.

Name (Mr / Mrs):

(Full name in BLOCK LETTERS)

2. Designation:

3. DOJ:

4. Department / Process:

5. Present Address & Contact No:

6. Permanent Address & Contact No:

7. Emergency Contact Name & Contact No:

(Signature of Candidate)

Date (dd/mm/yy): Name:

 (For Unexempted /Exempted Establishments)
NOMINATION AND DECLARATION FORM
(Declaration and Nomination Form under the Employees’ Provident Funds and Employees’ Pension Scheme)
(Paragraphs 33 and 61 (1) of the Employees’ Provident Funds Scheme, 1952 and paragraph 18 of the Employees’ Pension
Scheme, 1995)

1 Name (in Block Letters) :

2 Father’s/Husband’s Name :

3 Date of birth :

4 Sex :

5 Marital Status :

6 Account No. (PF/EPS Number) :

7 Address (Residential) :

Name and Address of Nominees Date of Birth Total amount If the nominee is minor, name and
the relationsh of share relationship and address of the
nominee/nominees ip with o guardian who may receive the
the f amount during the minority of
member accumulatio nominee
ns
is Provident
Fund to be
paid to

each
nominee (%)
(1) (2) (3) (4) (5)

1 * Certified that I have no family as defined in para 2(g) of the Employees’ Provident Funds Scheme, 1952, and should
I acquire a family hereafter, the above nomination should be deemed as cancelled.
2 * Certified that my father/mother is/are dependent upon me.
3. * Strike out whichever is not applicable.
X----------------------------------------------------------------
Signature or thumb impression of the
 Name of Address of the family member Date of Relationship with
S. No. Address
Name Birth member
(1) (2) (3) (4) (5)

*Certified that I have no family as defined in pare 2 (vii) of Employee's Pension Scheme, 1995 and should
*
acquire a family here after I shall furnished particulars thereon in the above form.
I hereby nominate the following persons for receiving the monthly widow pension (admissible under para 16 2(a) (i) and (ii)
of Employees’ Pension Scheme, 1995 in the event of my death without leaving any eligible family member for receiving
Pension. $$

Name and address of the Nominee, Date of Birth Relationship with the member
(1) (2) (3)

Dated the

X
**Strike out whichever is not applicable.
Signature or thumb impression of the
subscriber

CERTIFICATE BY EMPLOYER

Certified that the above declaration and nomination has been signed thumb impressed before me by Shri/Smt/Kum
DESETTI SIVASAI KUMAR employed in my establishment after he/she has read the entries have been read over to
him/her by me and got confirmed by him/her.

Place: Vizag Nasir

Pasha
Dated the
216102
XX
Signature of the Employer or other authorized Officer of the
establishment Designation Associate, People Solutions
Name & Address of the Factory/Establishment or Rubber Stamp there of
 1. Name of the member

2. Father’s Name Spouse’s

Name (Please tick whichever is
applicable)
3. Date of Birth: ( DD / MM / YYYY )
4. Gender: (Male/Female/Transgender)
5. Marital Status: (Married/Unmarried/Widow/Widower/Divorcee)
6 (a) Email ID:

(b) Mobile No.:

7 Whether earlier a member of Employees’ Provident Fund Scheme, 
1952
8 Whether earlier a member of Employees’ Pension Scheme, 1995 
Previous employment details: [if Yes to 7 AND/OR 8 above]
a) Universal Account Number:
b) Previous PF Account Number:
9 c) Date of exit from previous employment: (DD/MM/YYYY)
d) Scheme Certificate No. (if issued)
e) Pension Payment Order (PPO) No. (if issued)
a) International Worker:
b) If yes, state country of origin (India/Name of other country)
10 c) Passport No.
d) Validity of passport [(DD/MM/YYYY) to (DD/MM/YYYY)]
KYC Details: (attach self-attested copies of following KYCs)
a) Bank Account No. & IFC Code
11 b) AADHAR Number
c) Permanent Account Number (PAN), if available
UNDERTAKING
1) Certified that the particulars are true to the best of my knowledge.
2) I authorize EPFO to use my Aadhar for verification/authentication/e-KYC purpose for service delivery.
3) Kindly transfer the funds and service details, if applicable, from the previous PF account as declared above to the
present
P.F. Account. (The transfer would be possible only if the identified KYC detail approved by previous employer
has been verified by present employer using
his Digital
Signature Certificate)
4) In case of changes in above details, the same will be intimated to employer at the earliest.
Date
:
Place: Vizag Signature of Member

DECLARATION BY PRESENT EMPLOYER

A. The member Mr./Ms/Mrs. ………………………………….. has joined on.....................................and has been allotted PF
Number
………………………………….
B. In case the person was earlier not a member of EPF Scheme, 1952 and EPS, 1995:

(Post allotment of UAN) The UAN allotted for the member is ……………………………………
Please Tick Appropriate Option:
The KYC details of the above member in the UAN database
 Have not been uploaded
 Have been uploaded but not approved
 Have been uploaded and approved with DSC
C. In case the person was earlier a member of EPF Scheme, 1952 and EPS, 1995:
The above PF Account Number/UAN of the member as mentioned in (A) above has been tagged with
his/her UAN/Previous Member ID as declared by member
Please Tick the Appropriate Option:-
 The KYC details of the above member in the UAN database have been approved with
E-sign/Digital Signature Certificate and transfer request has been generated on portal.
 As the DSC of establishment are not registered with EPFO, the member has been informed
to file physical claim (Form- 13) for transfer of funds from his previous establishment.
Date: Signature of Employer with Seal of Establishment
 CONCENTRIX DAKSH SERVICES INDIA
PVT LTD [Link]-9-13-45-2/9/4(3), WARD NO-
16
7TH FLOOR, SRK DESTINY, VIP ROAD, VIZAG-530003

x DESETTI SAMBA SIVA RAO Father 52 100%

`

VIZAG X

xx

D Hareesh Patnaik
MIG 29 MVP Sector 6 Vizag -
530003
Anand Kumar
MIG 29 MVP Sector 6 Vizag -
530003
VIZAG

xx

NASIR PASHA
216102 ASSOCIATE, PEOPLE SOLUTIONS

X
 FORM-I
NOMINATION AND DECLARATION FORM
(See rule 3)

[Link] of person making

nomination (in block letters)
[Link]'s/Husband's Name
[Link] of Birth
[Link]
[Link] Status
[Link] Address

[Link] Address

I hereby nominate the person(s)/cancel the nomination made by me previously and nominate the person(s) mentioned below to receive
any amount due to me from the employer, in the event to my death.
x
Name of the Address Nominee’s Date of Birth Total amount of If the nominee is minor,
nominee/nominees relationship with the share of name, relationship and
member accumulations in address of the guardian
credit to be paid to who may receive the
each nominee amount during the
minority of nominee.
1 Certified that I have no family, and should I acquire a family (Spouse, Children) hereafter, the above nomination shall be deemed as cancelled.
2 Certified that my father/mother is/are dependent upon me.
3 *Strike out whichever is not applicable.
4 **Family means Dependent Parents / Spouse / Children - As per Payment of Wages Act, 1936

X
Signature or the thumb impression of the
employed person

CERTIFICATE BY EMPLOYER

Certified that the above declaration and nomination has been signed/thumb impressed before me by

Shri/Smt./Kum employed in my establishment after he/she has read the entry/entries have

been read over to him/her by me and got confirmed by

him / her.
xx
NASIR PASHA 216102
ASSOCIATE, PEOPLE
SOLUTIONS
Signature of the employer or other authorised
officer of the establishment and Designation

Place: VIZAG
Name and Address of the Factory/Establishment and
Date : rubber stamp thereof.
 DECLARATION FORM FORM - 1
To be filled in the employee after reading instructions overleaf . Two
postcard Size photographs are to be attached with this form .This
form is free of cost
AADHAAR NO : * 480373360439
Mobile No * 9491548630
(A) INSURED PERSON's PARTICULARS (B) EMPLOYER'S PARTICULARS
1. Insurance No. if any * 9. Employer's Code No.
R
2. Name (in block letters) * 10. Date of Day Month Year
Appointment
3. Father's /Husband's Name
Entry
*
[Link] of birth * D M Y Marital Status Gender 11. Name & Address of the Employer

26.08.1994 Singl MALE CONCENTRIX DAKSH SERVICES INDIA PVT LTD

e [Link]-9-13-45-2/9/4(3), WARD NO-16
7. Present Address * 8. Permanent Address * 7TH FLOOR, SRK DESTINY, VIP ROAD, VIZAG-530003

12. In case of any previous employment please fill up

the detail as under :-

a) Previous Ins. No.

Pin Code
b) Emplr's. Code No.
Pin Code
c) Name & address of the employer

Detail of Nominee *
Name Relations
hi Address
p
DESETTI SAMBA Father 37-12-64/5/A/SF-201, ANJINADRI ENCLAVE, NGOS
SIVA RAO COLONY, NG
,VISAKHAPATNAM,Andhra Pradesh,530007

Bank a/c Details is Mandatory * (in case bank a/c not available can fill bank a/c details of any member of the family which can be
changed subsequently)
Name of Bank Branch Bank A/C No IFSC Code MICR Code

I hereby declare that the particulars given by me are correct to the best of my knowledge
and belief . I undertake to intimate the corporation any charges in the membership of my
family within 15 days of such change.

Counter signature by the employer

216102
Nasir Pasha
Associate, People Solutions
Signature with seal Signature /T.I Of IP

(D) FAMILY PARTICULARS OF INSURED PERSON

Sl. Name Date of Relationshi Whethe If 'No' state place of Residence

Birth/Age p with r Town Aadhaar No Stat
No. as on date the residin e
of Employ g with
filling form e him/her?
e

1.

2.

3.
4.

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

ESI Corporation
Temporary Identity Card (valid for 3 months from the date of appointment)
 DESETTI SIVASAI KUMAR
Name

[Link]

Branch Office

Employer's Code No.& Address

a lid i
eD a
d :t
tV y :
21.03.2 Signature/T.I of I.P Signature of B.M. with seal
0
22
 INSTRUCTIONS

1. Submission of Form -1 is governed by regulations 11 & 12of ESI (General) Regulations, 1950

2. "family" means all or any of the following relatives of an insured Person namely :-
(I) a spouse (ii) a minor legitimate or adopted child dependent upon the I.P.; (iii) a child who is wholly dependant on the
earnings of the
I.P. and who is (a ) receving educations , till he or she attains the age of 21 years ( b ) an
unmarried daughter ; ( iv ) a child who is infirm by reason of any physical or mental
abnormality or injury and is wholly dependant on the earnings of the I.P. so long as the
infirmity continues ; ( v ) dependant parents ( Please see Section 2 clause 11 of the ESI Act
1948 for details).

3. Identity Card is Non - transferable.

4. Loss of Identity Card be reported to Employer/Branch Manager immediately.

5. Submission of false information attracts penal action under Section 84 of ESI Act,1948.

6. This form duly filled in must reach the concerned Branch Office within 10days of
appointment of an Employee. Delayattracts penal action under Section 85 for the Act,
against employer.

[Link] an insured person you and your dependent family members are entitled to full
medical care . The other benefit incase include ( 1 ) Sickness benefit ( 2 ) Temporary
Disablement Benefit ( 3 ) permanent Disablement Benefit ( 4 )Dependents benefit and
( 5 ) Maternity Benefit ( in case of women employees ) subject to fulfillment of
contributory conditions.

8. For more details please visit website of ESIC at [Link] or contact Regional office or Branch Office.
9. All * mark filed are mandatory name should be as per aadhaar of employee and member's of family

………………………………………………….…………………………………………………………………………………………………………
……………………..
 CONFLICT OF INTEREST DISCLOSURE FORM

DESETTI SIVASAI KUMAR Vizag WHEELZ

Name (please print) Location and Department

Representative, Operations

Date 21.03.2022 Job Title

It is the policy of Concentrix Corporation and each of its subsidiaries and affiliates (the “Company”) to
address how issues of actual, potential and perceived conflicts of interest involving employees of the
Company should be identified, disclosed and managed. This form is designed to identify and disclose such
conflicts in an effort to properly manage them.

I have read the Company Code of Ethical Business Conduct and understand that as an employee of the Company
it is my obligation to act in a manner which promotes the best interests of the Company and to avoid conflicts of interest
when making decisions and taking actions on behalf of the Company.

My answers to this disclosure form are correctly stated to the best of my knowledge and belief. Should a
possible conflict of interest arise in my responsibilities to the Company, I recognize that I have the obligation to notify
the appropriate designated contact (Manager, People Solutions, or Legal), and to abstain from any participation in the
matter until the Company can determine whether a conflict exists and how that conflict should be resolved. If any
relevant changes occur in my affiliations, duties, or financial circumstances, I recognize that I have a continuing
obligation to file

Signature Date

1. Are you or a member of your immediate family an employee or consultant of a customer or vendor that presently
has material business dealings with either Concentrix Corporation or any Concentrix subsidiary, (collectively the
“Company”) or which might reasonably be expected to have material business dealings with the Company in the
coming year? Immediate family is defined as: spouse, parents and grandparents, children and grandchildren,
brothers, sisters, mother-in-law and father-in-law, brother-in-law and sister-in-law, daughter- in-law and son-in-
law, and adopted and step members.

Yes

If yes, please list the name of the customer or vendor, the position held, and the nature of the business which is
currently being conducted with the Company or which may reasonably be expected to be conducted with the
Company in the coming year:

February 17, 2021 Page 1

 2. Do you or does any member of your immediate family have a material financial interest, direct or
indirect, in a customer or vendor which currently has material business dealings with the Company
or which may reasonably be expected to have such business dealings with the Company in the
coming year?

 Yes No

If yes, please list the name of the customer or vendor, the nature of the interest and the name of the person
holding the interest, and the nature of the business which is currently being conducted with the Company or
which may reasonably be expected to be conducted with the Company in the coming year:

3. Have you or an immediate family member accepted gifts, gratuities, lodging, dining, or
entertainment that might reasonably appear to influence your judgment or actions concerning the
business of the Company?

 Yes

If yes, please provide details below:

4. Are you aware of any other facts or circumstances that might reasonably appear to be actual,
potential or perceived conflicts of interest involving employees of the Company?

 Yes

If yes, please provide details below:

February 17, 2021 Page 2

 Receipt and Acknowledgement

I have received a copy of our Company’s Code of Ethical Business

Conduct and have read it carefully. I understand all of the guidelines,
practices, and policies and agree to abide by them.

I understand and agree that if I violate the guidelines, practices, and

policies in the Code of Ethical Business Conduct that I can be
disciplined for my conduct and may even be terminated.

I understand that our Company reserves the right to change, amend,

or delete any or all of the information contained in this Code of Ethical
Business Conduct at any time as dictated by circumstances of the
business.

I further understand that signing this Receipt and Acknowledgment

form does not, nor is it intended to, confer any rights or benefits or
employment, or constitute an assurance of continued employment or
employment other or employment other than at will.

Signature:

Date:

Printed Name:

Employee Number:

Company: Concentrix

Locations: Vizag

Waivers of any provision of the Code are generally not permitted and,
in any event, may be granted only by the Board of Directors in writing
and must be disclosed in accordance with applicable law. This Code of
Ethical Business Conduct may be amended from time to time at our
Company’s discretion. The current version of the Code will be posted
and maintained on our Company’s intranet sites and can be obtained
from Human Resources or the Legal Department.

42

Concentrix
Corporation Code of
Ethical Business
Conduct
 Agreement Regarding Confidential Information, Intellectual Property and Other Matters

In consideration of my employment or my continued employment by Concentrix (which includes Concentrix Daksh Services
India Private Limited or Concentrix Services India Private Limited or Concentrix Technologies India Private Limited or
Convergys India Services Private Limited as applicable) which I acknowledge is employment at will, and the payment to me of
a salary or other compensation during my employment, I agree as follow:

1. I will not, without Concentrix’s prior written permission, disclose to anyone outside of Concentrix or use in other than
Concentrix’s business, either during or after my employment, any confidential information or material of Concentrix,
or any information or material received in confidence from third parties, such as suppliers or customers, by
Concentrix. If I leave the employment of Concentrix, I will return to Concentrix all property in my possession
belonging to Concentrix or received from any third party by Concentrix, whether or not containing confidential
information, including, but not limited to, diskettes and other storage media, drawings, notebooks, reports, and
other documents.
Confidential information or material of Concentrix is any information or material: (a) generated or collected by or
utilized in the operations of Concentrix , received from any third party, or suggested by or resulting from any task
assigned to me or work performed by me for or on behalf of Concentrix , and (b) which has not been made
available generally to the public, whether or not expressed in a document or other medium and whether or not
marked "Concentrix Confidential" or with any similar legend of Concentrix or any third party. Confidential
information or material may include, but is not limited to, information and material related to past, present and
future development, operational activities, or personnel matters; marketing and business plans; technical
specifications, drawings, and designs; prototypes; computer programs; and databases.

2. During my employment with Concentrix and for one year following the termination of my employment for any
reason, I will not directly or indirectly: a) hire, solicit or make an offer to any employee of Concentrix to be
employed or perform services outside of Concentrix; or b) solicit for competitive business purposes any
customer of Concentrix with which I have been involved as part of my job responsibilities during the last year of
my employment with Concentrix. I acknowledge that Concentrix would suffer irreparable harm if I fail to comply
with the foregoing.

3. I will not disclose to Concentrix for use in its business, or cause it to use, any information or material which is
confidential to any third party unless authorized by such third party in writing. In addition, I will not incorporate into
any services provisioned by Concentrix any copyrighted materials of any third party, unless authorized by
Concentrix.

4. I will comply, and do all things necessary for Concentrix to comply, (a) with the laws and regulations of all
governments under which Concentrix does business, (b) with provisions of contracts between any such government or
its contractors and Concentrix that relate to intellectual property or to the safeguarding of information, and (c) with all
of the Concentrix Business Conduct Guidelines as amended from time to time.

5. This Agreement supersedes all previous oral or written communication, representations, understanding,
undertakings, or agreements relating to the subject matter hereof. Any waiver of a term in this Agreement and any
amendment to this Agreement may only be made in a writing signed by an authorized signatory of Concentrix and
myself.

6. Although I may work for the Company outside of India I understand and agree that this Agreement shall be
governed by the laws of India. If any provision of this Agreement is unenforceable by law, the remainder shall
remain in effect.

7. I recognize that any violation of my obligations described herein can result in disciplinary action, including
dismissal from Concentrix, and any other appropriate relief for Concentrix including money damages, equitable
relief and attorney’s fees.

Signature of the Employee

My Agreement, and my acknowledgment of receipt of a copy of this Agreement, is indicated by my signature below.

Name of Employee: Employee’s Manager/Concentrix Rep: NASIR PASHA

Date (dd/mm/yy):
Date (dd/mm/yy):
Concentrix Signature:
Signature of Employee: X
Employee ID:
Employee ID:

The following are Developments, in which I have any right, title, or interest, and which were previously conceived or
written either wholly or in part by me, but neither published nor filed in any Patent Office:

Title on Document Date on Document Name of Witness on

Document

Signed:

Employee's Full Name

Date:

(It is in your interest to establish that any of the above were made, conceived, or written before your employment by Concentrix.
You should not disclose them in detail but identify them only by the titles and dates of documents de-scribing them. If you wish to
draw interest of Concentrix in any of them, you may contact the Intellectual Property and Licensing Department, which will provide
you with instructions for submitting them to Concentrix.)
 PROPRIETARY INFORMATION AND INVENTIONS AGREEMENT

The following Agreement confirms certain terms of my employment with Concentrix (which includes Concentrix Daksh
Services India Private Limited or Concentrix Services India Private Limited or Concentrix Technologies India Private
Limited or Convergys India Services Private Limited as applicable) which is a material part of the consideration for my
employment by the Company and the compensation received by me from the Company from time to time. The headings
contained in this Agreement are for convenience only, have no legal significance, and are not intended to change or
limit this Agreement in any matter whatsoever.

A. Definitions

1. The “Company”

“Company” means Concentrix (which includes Concentrix Daksh Services India Private Limited or
Concentrix Services India private limited or Concentrix Technologies India Private limited or Convergys India Services
Private Limited as applicable) and shall mean and include all its subsidiaries, or affiliated companies.

I recognize and agree that my obligations under this Agreement and all term of this Agreement apply to me regardless
of wheth er I am employed by or work for Concentrix or any other subsidiary or affiliated company of CONCENTRIX.
Furthermore, I understand and agree that the terms of this Agreement will continue to apply to me even if I transfer at
some time from one subsidiary or affiliate of Concentrix to another.

2. “Proprietary Information”

I understand that the Company possesses and will possess Proprietary Information which is important to its business. For
purposes of this Agreement, “Proprietary Information” is information that was or will be developed, created, or discovered
by or on behalf of the Company, or which became or will become known by, or was or is conveyed to the Company, which
has commercial value in the Company’s business.

“Proprietary Information” includes, but is not limited to information about software programs, subroutines and related
documentation, source and object code, algorithms, trade secrets, designs technology, know-how, processes, data, ideas,
concept, techniques, inventions (whether patentable or not), works or authorship, mask works and the like, formulas,
business and product development plans, customer lists, terms of compensation and performance levels of Company
employees, Company customers and other information concerning the Company’s ac tual or anticipated business, research
or development, or which is generated, collected or received in confidence by or for the Company from any other person.

I understand that my employment creates a relationship of confidence and trust between the Company and me with respect to
Proprietary Information.

3. “Company Documents and Materials”

I understand that the Company possesses or will possess “Company Documents and Materials” which
are important to its business. For purposes of this Agreement, “Company Documents and Materials” are documents or
other media or tangible items that contain or embody Proprietary Information of any other information concerning the
business, operations or plan of the Company, whethe r such documents, media or items have been prepared by me or
by others.

“Company Documents and Material” include, but are not limited to, blueprints, drawing, photographs,
charts, graphs, notebook, customer lists, computer disks and other storage media, tapes or printouts, sound recordings
and other printed, typ ewritten or handwritten documents, sample products, prototypes and models.

Signature of Employee
B. Assignment of Rights

All Proprietary Information, and all patents, patent rights, copyrights, trade secret rights, trademark rights
and other rights (including, without limitation; intellectual property rights) anywhere in the world in connection with
Proprietary Information, is and shall be the sole property of the Company. I hereby assign to the Company any and all
rights, title and interest I may have or acquire in such Proprietary Information.
At all times, both during my employment by the Company and after its termination, I will keep in confidence
and trust and will not use or disclose any Proprietary Information or anything relating to it without the prior written
consent of an officer of the Company, except as may be necessary in the ordinary course of performing my duties to the
Company.

C. Maintenance and Return of Company Documents and Materials

I agree to make and maintain adequate and current written records, in a form specified by the Company,
of all inventions, trade secrets and works of authorship assigned or to be assigned to the Company pursuant to this
Agreement. All Company Documents and Material are and shall be the sole property of the Company.

I agree that during my employment by the Company, I will not remove any Company Documents and
Material from the business premises of the Company or deliver any Company Document and Materials to any person or
entity outside the Company, except as I am required to do in connection with performing the duties of my employment. I
further agree that, immediately upon the termination of my employment by me or by the Company for any reason, or
during my employment if so requested by the Company, I will return all Company Documents and Material, apparatus,
equipment and other physical property, or any reproduction of such property, any third party information/ Customer
related Information whether or not containing confidential Information, including, but not limited to diskettes, and other
storage media, drawings, notebooks, reports, and other documents excepting only (i) my personal copies of records
relating to my compensation; (ii) my personal copies of any material previously distributed generally to stockholders of
the Company; and (iii) my copy of this Agreement.

D. Disclosure of Inventions to the Company

I will promptly disclose in writing to my immediate supervisor or to such other person designated by the
Company all “Inventions,” which includes, without limitation, all software programs or subroutines, source or object code,
algorithms, improvements, inventions, works of authorship, trade secrets, technology, designs, formulas, ideas,
processes, techniques, know-how and data, whether or not patentable, made or discovered or conceived or reduced to
practice or developed by me, either alone or jointly with others, during the term of my employment.

I will also disclose to the President of the Company all Inventions made, discovered, conceived, reduced to
practice, or developed by me within six (6) months after the termination of my employment with the Company which
resulted, in whole or in part, from my prior employment by the Company. Such disclosures shall be received by the
Company in confidence (to the extent such Inventions are not assigned to the Company pursuant to Section (E) below)
and do not extend the assignment made in Section (E) below.

Signature of Employee
E. Rights to New Ideas

1. Assignment of Inventions to the Company

I hereby assign to Concentrix my entire right, title, and interest in any idea, concept, technique, invention, design,
computer programs and related documentation, other works of authorship, mask works, and the like (all hereinafter
called "Inventions"), hereafter made, conceived, written, or otherwise created solely or jointly by me, whether or not
such Inventions are patentable, subject to copyright protection or susceptible to any other form of protection which: (a)
relate to the actual or anticipated business or research or development of Concentrix or its subsidiaries or (b) are
suggested by or result from any task assigned to me or work performed by me for or on behalf of Concentrix or its
subsidiaries.

The above provisions concerning assignment of Inventions apply to Inventions created while I am employed by
Concentrix whethe r in an executive, managerial, professional, product or technical planning, technical, research,
programming, or engineering capacity (including development, product, manufacturing, systems, applied science, and
field engineering).

In connection with any of the Inventions assigned as above: (a) I will promptly disclose them in writing to the
Concentrix Law Department; and (b) I will, on Concentrix’s request, promptly execute a specific assignment of title to
Concentrix or its designee, and do anything else reasonably necessary to enable Concentrix or such designee to secure
a patent, copyright or other form of protection therefore in the India and in other countries. In addition, I agree to
promptly notify the Concentrix Law Department in writing of any patent or patent application in which I am an inventor,
but which is not assigned as detailed under List of Inventions herein below and which discloses or claims any Invention
made, conceived, or written while I am employed by Concentrix.

Concentrix and its licensees, successors, or assigns (direct or indirect) are not required to designate me as an author of
any Invention which is subject to this Agreement, when it is distributed, publicly or otherwise, or to secure my
permission to change or otherwise alter its integrity. I hereby waive and release, to the extent permitted by law, all
rights in and to such designation and any rights I may have concerning modifications of such Inventions.

I understand that any rights, waivers, releases, and assignments herein granted and made by me are freely assignable
by Concentrix and are for the benefit of Concentrix and its subsidiaries, licensees, successors, and assigns.

2. Works Made for Hire

The Company shall be the sole owner of all patents, patent rights, copyrights, trade secret rights,
trademark rights and all other intellectual property or other rights in connection with Inventions. I further acknowledge
and agree that such Inventions, including, without limitation, any computer programs, programming documentation, and
other works of authorship, are “works made for hire” for purposes of the Company’s rights under copyright laws. I
hereby assign to the Company any and all rights, title and interest I may have or acquire in such Inventions. If in the
course of my employment with the Company, I incorporate into a Company product, process or machine a prior
Invention owned by me or in which I have interest, the Company is hereby granted and shall have a nonexclusive,
royalty-free, irrevocable, perpetual, sublicensable, worldwide license to make, have made, modify, use, market, sell, and
distribute such prior Invention as part of or in connection with such product, process or machine.

Signature of Employee

1|Page CNXALL/ONB/ART/ONBP/PIAIA/1.0
 3. Cooperation

I agree to perform, during and after my employment, all acts deemed necessary or desirable by the
Company to permit and assist it, at the Company’s expense, in further evidencing and perfecting the assignments made
to the Company under this Agreement and in obtaining, maintaining, defending and enforcing patents, patent rights,
copyrights, trademark rights, trade secret rights or any other rights in connection with such Inventions and
improvements thereto in any and all countries. Such acts may include, but are not limited to, execution of documents
and assistance of cooperation in legal and proceedings. I hereby irrevocably designate and appoint the Company and its
duly authorized officers and agents, as my agents and attorney-in-fact to act for and on my behalf and instead of me, to
execute and file any documents, applications or related finding and to do all other lawfully permitted acts to further the
purposes set forth above in the Subsection 3, including, without limitation, the perfection of assignment and the
prosecution and issuance of patents, patent applications, copyright applications and registrations, trademark
applications and registrations or other rights in connection with such Inventions and improvements thereto with the
same legal force and effect as if executed by me.

4. Assignment or Waiver of Moral Rights

Any assignment of copyright hereunder (and any ownership of a copyright as a work made for hire) include
all rights of paternity, integrity, disclosure and withdrawal and any other rights that may be known as or referred to as
“moral rights” (collectively “Moral Rights”). To the extent such Moral Rights cannot be assigned under applicable law
and to the extent the following is allowed by the laws in the various countries where Moral Rights exist, I hereby waive
such Moral Rights and consent to any action of the Company that would violate such Moral Rights in the absence of such
consent.

5. List of Inventions

I have attached hereto as Exhibit A a complete list of all inventions or improvements to which I claim
ownership and that I desire to remove from the operation of this Agreement, and I acknowledge and agree that such list
is complete. If no such list is attached to this Agreement, I represent that I have no such inventions or improvements at
the time of signing this Agreement.

F. Non-Solicitation of Company Employees

During the term of my employment and for one (1) year thereafter, I will not encourage or solicit any
employee of the Company to leave the Company for any reason or to accept employment with any other company. As
part of this restriction, I will not interview or provide any input to any third party regarding any such person during the
period in question. However, this obligation shall not affect any responsibility I may have as an employee of the
Company with respect to the bona fide hiring and firing of Company personnel.

G. Company Authorization for Publication

Prior to submitting or disclosing for possible publication or dissemination outside the Company any material
prepared by me that incorporates information that concerns the Company’s business, I agree to deliver a copy of such
material to an officer of the Company for his or her review. Within twenty (20) days following such submission, the
Company agrees to notify me in writing whether the Company believes such material contains any Proprietary
Information or Inventions, and I agree to make such deletions and revisions as are reasonably requested by the
Company to protect its Proprietary Information and Inventions. I further agree to obtain the written consent of the
Company prior to any review of such material by persons outside the Company.

Signature of Employee
H. Duty of Loyalty

I agree that, during my employment with the Company, I will not provide consulting services to or become
an employee of, any other firm or person engaged in a business in any way competitive with the Company, without first
informing the Company of the existence of such proposed relationship and obtaining the prior written consent of my
manager and the Human Resource Manager responsible for the organization in which I work.

I. Former Employer Information

I represent that my performance of all the terms of this Agreement and as an employee of the Company
does not and will not breach any agreement to keep in confidence proprietary information, knowledge or data acquired
by me in confidence or in trust prior to my employment by the Company, and I will not disclose to the Company or
induce the Company to use any confidential or prop rietary information or material belonging to any previous employer
or others. I have not entered into and I agree I will not enter into any agreement, either written or oral, in conflict
herewith or in conflict with my employment with the Company. I further agree to conform to the rules and regulation of
the Company.

J. Severability

I agree that if one or more provisions of this Agreement are held to be unenforceable under applicable law,
such provisions shall be excluded from this Agreement and the balance of the Agreement shall be interpreted as if such
provision were so excluded and shall be enforceable in accordance with its terms.

K. Authorization to Notify New Employer

I hereby authorize the Company to notify my new employer about my rights and obligations under this
Agreement following the termination of my employment with the Company.

L. Entire Agreement

This Agreement sets forth the entire agreement and understanding between the Company and my relating
to the subject matter herein and merges all prior discussions between us, including but not limited to any and all
statements made by any officer, employee or representative of the Company regarding the Company’s financial
condition or future prospects. I understand and acknowledge that, except as set forth in this Agreement and in the offer
letter from the Company to me, (i) no other representation or inducement has been made to me, (ii) I have relied on my
own judgement and investigation in accepting my employment with the Company, and (iii) I have not relied on any
representation or inducement made by any officer, employee or representative of the Company. No modification of or
amendment to this Agreement nor any waiver of any rights under this Agreement will be effective unless in a writing
signed by the President of the Company and me. I understand and agree that any subsequent change or changes in my
duties, salary or compensation will not affect the validity or scope of this Agreement.

M. Effective Date

This Agreement shall be effective as of the first day of my employment with the Company and shall be
binding upon me, my heirs, executor, assigns and administrators and shall inure to the benefit of the Company, its
subsidiaries, successors and assigns.

Signature of Employee
N. Governing Law

Although I may work for the Company outside of India, I understand and agree that this Agreement shall be
interpreted and enforced in accordance with the laws of India.

I recognize that any violation of my obligations described herein can result in disciplinary action, including dismissal from
/Company, and any other appropriate relief for Company including money damages, equitable relief and attorney’s fees
as the Company may deem fit.

I HAVE READ THIS AGREEMENT CAREFULLY AND I UNDERSTAND AND ACCEPT THE OBLIGATIONS WHICH IT IMPOSES UPON
ME WITH OUT RESERVATION. NO PROMISES OR

REPRESENTATIONS HAVE BEEN MADE TO ME TO INDUCE ME TO SIGN THIS AGREEMENT. I SIGN THIS
AGREEMENT VOLUNTARILY AND FREELY.

Date

X
Employee Signature

Employee Name (Please Print)

2|Page CNXALL/ONB/ART/ONBP/PIAIA/1.0
 EXHIBIT A

1. The following is a complete list of all inventions or improvement relevant to the subject matter of my employment
by the Company that have been made or discovered or conceived or first reduced to practice by me or jointly with
others prior to my employment by the Company that I desire to remove from the operation of the Company’s Proprietary
Information and Inventions Agreement:

No Inventions or improvements.

See below: Any and all inventions regarding:

Additional sheets attached.

2. I propose to bring to my employment the following material and documents that I obtained during the period of my
prior employment. These materials and documents are not the property of any third party and are not subject to any
restrictions under any non-disclosure agreement or other agreement limiting their use.

No materials or

documents See below:

X
Employee Signature

Date
 SELF DECLARATION FOR NAME MISMATCH

I DESETTI SIVASAI KUMAR residing at

The name mentioned in my Pan card is

The name in my Passport is

The name in my Aadhaar is

The name in my SSC (10th) Marksheet/Certificate is

The name in my HSC (12th) Marksheet/Certificate is

The name in my Graduation ([Link]/B.A…) Marksheet/ Passing Certificate is

The name in my Post Graduation ([Link]/M.A…) Marksheet/ Passing Certificate is

The name in my Other Educational document (Diploma/Professional Course…) Marksheet/ Passing Certificate is

The name in the Experience/Reliving Letter for

is

I declare that all the above names are one and the same person. I declare that my correct name is

The averments in the declaration mentioned above are true and if found later to be false, the company will have the liberty to
proceed appropriately against the employee for perjury.

Date:

SIGNATURE OF CANDIDATE:
 CRIMINAL BACKGROUND VERIFICATION FORM

Employee Name Emp ID

Photo of the
DOB Contact No.
employee.
Father / Mother /Husband’s Name DESETTI SAMBA SIVA RAO Cross sign
the photo.
Details required for Criminal Background Verification / Address Verification

Please provide following address details:

1) 2 years of Present Address (including Past Address, incase duration at Present Address is less than 2 years)
2) Permanent address.
Please fill all the details correctly & appropriately including Point of reference with their contact details.

Police Duration of stay at Point of Reference# along with Contact details

Complete Address Details station/ the address
S. No provided
with phone number (if any) District /
State Start Date End Date
(Approx) (Approx) Name of Address of Phone
(MM-YY) (MM-YY) Contact the No.
contact

2 Past** Address 1

3
Past** Address 2

4
Past** Address 3

* Present Address: Address where you are currently staying

** Past Address: Address(es) where you were staying prior to your Present address in last 2 years
***Permanent address: Address where you are permanently residing, irrespective of Present address, and where
communications to you may be sent. This is typically your parent’s residence, or an address in your home town. This can
be a rented property also. This may or may not be the same as your present and past addresses.
# Reference: Could be your Parents, Spouse, Neighbors, Friends, Relatives, Roommate who stayed with you etc.
or staying in close neighborhood Note: All fields are Mandatory as per applicability.
Self-Declaration:
I understand and agree that Concentrix (which includes Concentrix Daksh Services India Private Limited or Concentrix Services India
Private Limited or Concentrix Technologies India Private Limited or Convergys India Services Private Limited as applicable) has required
that I either submit a valid passport to Concentrix or undergo certain background checks (including criminal record verification). As I have
not submitted a valid passport, I understand that I will be required to undergo these background checks and as per the terms and
conditions mentioned in your Appointment letter’

In this connection, I specifically authorize Concentrix to deduct cost up to INR 1500/- of such background checks from my payroll
and shall not raise any claims against Concentrix with respect to the deduction of such amounts."

I hereby, declare that the above-mentioned information provided by me is true to the best of my knowledge &

belief. I understand that the above information furnished by me will be used for conducting Background

Verification by the
Organization/Third Party Vendor appointed by Organization. I have no objection to the conduct of such background verification by
any third party/ vendor approved by Concentrix.
I hereby authorize them to undertake verification of my background and criminal records / previous addresses through police/ any other
authorities.
If any of the above-mentioned information is found to be fraudulent or incorrect or negative record/report found during the background
verification, the Company has the right to take appropriate disciplinary action against me, including Termination.
Date Signature of the employee
CNXALL/ONB/ART/ONBP/CBV/1.0
 REQUISITION FOR "CONCENTRIX EMPLOYEE" PHOTO ID BADGE

`TO: Security Control Room Date: 21.03.2022 Version 3.2

EMPLOYEE DETAILS PHOTO

FULL NAME (As

Per WD)

EMPLOYEE ID

REASON

DATE OF

JOINING

PROCESS

(White Background Passport Size Photo

Only)
PERIOD From / / to / /
* For Fixed Term Hire (FTH) Specify Duration (DD/MM/YYYY)
HUMAN RESOURCE (HR) REPRESENTATIVE APPROVAL
*Applicable for New Joinee, Extension and Lost

NAME Nasir Pasha

216102
EMPLOYEE ID

SIGNATURE

PSCA MANAGER (PRIMARY / SECONDARY) APPROVAL AUTHORIZATION TO CARRY RESTRICTED

ITEMS ON THE FLOOR
(Please put tick mark against icons
below)

NAME PEN
EMPLOYEE ID LAPTOP
MOBILE (CAMERA / NON –
CAMERA) STAR (NO
RESTRICTION)
FOR ACCESS REQUEST ONLY DATE OF RECEIPT : / /

BRT REQUEST #
BADGE
CONTROL #
LOCATION /
SITE

Signature :
(ACCESS CONTROL STAFF)
Note:
1. Authorization icons are applicable for Specific Business where employees name is reflected in the authorization list.
2. For 'STAR' category, employee has to obtain necessary approvals from all businesses of location and share with
Security to process the badge.
3. Special Category icons (Star, Pen, Mobile, and Laptop) applies to employee Base location only. For all other building’s
employee may be requested to show his / her name in the authorization list.
4. This form has to be submitted at the respective location Security Control Room. Badge will be delivered within 7 to 10
working days after submission of form.
5. Access to any Project Specific Controlled Area (PSCA) can be requested via PSCA Online Tool as per the process.
6. Please report loss of badge to Security / Control Room (SCR) immediately.
7. If you have lost or misplaced your ID badge, necessary deduction will be done as per policy from your salary
through payroll to process replacement badge.

DESETTI SIVASAI KUMAR

NEW JOINEE YES / NO

LOST
UNUSABLE
22.03.2022
WHEELZ

Vizag
 ONBOARDING CHECKLIST
Name of
Candidate: DESETTI SIVASAI
KUMAR
Pls Note: All documents must be signed
by the employee with Name and Date.
However, Onboarding SPOC need not sign all documents, common sign off on checklist would suffice and
would mean that all document marked on the checklist
have been checked and verified by the HR SPOC
Serial Documents required Onboardi EDC SPOC/Top X SPOC
No. Undergraduate: If the person is undergraduate or pursuing graduation, ng SPOC
then proof required of 12 years of formal education and candidate should
be 18 years of age. Yes
NA
1 For Final Year Result Awaited: Proof of 12 years of formal education and
EDUCA 1st & 2nd year mark sheets or consolidated mark sheet for both years with Yes
TIONAL no backlogs.
CERTIFI NA
CATES Graduate: In case of Degree any document issued by the university /
(Self institute / from where the certificate has been issued, needs to certify Yes
Attested either scores / grades / "PASS" status with the duration clearly mentioned.
) NA
The
same needs to be verified by the Onboarding SPOC for
Internet Mark sheets completion and correctness. No 10th or 12th required.
are also OR
accepted In case of 3 years (or more) Diploma, he/she needs to provide Diploma
(Docume certificate / mark sheets for 3 years or proof of 15 years of formal Yes NA
nts to be education. Only 12th class certificate required along with Diploma
Check not Yes NA
checked
through Education Document with Roll/Registration Number has been attached Yes NA to be done
Website, by EDC
In addition to above any Professional Qualification (Post Graduation
if reqd), Certificate / Provisional Certificate) or any other Professional / Diploma
/ Degree certification to be attached if completed / passed
Name of the Company (To be Entered by Onboarding SPOC) - All companies relevant experience in Application Form /
Prospective Employee Detail’s should be mentioned here
(NO ORDER REQUIRED)
2
Company Name

Company Name

Company Name

Company Name

Company Name

Company Name

WORK
EXPERIEN
CE
CERTIFICA Any document issued by the company
1

with Joining and Relieving dates can

TES (Self
be taken. List of options for both
Attested)
joining and relieving dates are given
(For
below:
employ
ments as
declared
by the
applicant Proof to be collected for DOJ Note: Refer to FAQ for Document Types.
in the
Prospecti 1) Any official document issued by
ve the company on a Letter Head
Employee with Authorized Signatories
Detail’s mentioning DOJ (Pls mention the
/Applicati document name)
on Form)
Experienc
e
Checking

guidelines
12 & CL 11: or in case it is not on a Letterhead then it should tures and
For CL
signa
Experien Y have Yes
stamp from a Company Official. Note: es
ce Refer to FAQ for Document Types. Yes YesYes Yes
documen
ts to be
checked
upto
1 year of
employme
nt prior to
joining
Concentrix
 (which
includes iPsronoft to be collected for Last Working Day/Last Day in Organization the Service/Experience Certificate as mentioned above
Concentri submitted or the last working date is not mentioned clearly in these
x Daksh documents - Any one of the following documents Note: Refer to FAQ for
Services Document Types.
India
Private
Limited
or
Concentrix Services 2) Any official document issued by the company on a Letter Head with
Authorized Signatories mentioning LWD / LDO / Date of relieving /
India private limited End Date is mentioned
Concen Contract
or (Please mention the document name) Yes Yes
trix
Technologies India Note: Refer to FAQ for Document Types. Yes Yes Yes Yes
Private
Limited or
Convergy
s India
Services
Pvt Ltd as
applicable)
.
For CL 10 to CL 5:
up to 3 Other Alternatives for LWD / LDO
years of
employme Y Y Y Y Y  Yes
3) Any Salary Slip of the last 3 es es es es es
months
nt prior to from
joining the LWD along with Self Declaration of
Concentrix
1. JAF/Application employment –

form Refer
Y Y Y Y  Yes
/Prospect Artifa
ive Yes es es
ct s
OR
es es
Any
Employee from Bank Statement of the last 3 months
the LWD / Pass Book entry
Detail’s
would be
the
primary source of mentioning the Name of the Organization/candidate or Employee ID along with Self
checking employees Declaration of employment
experience by the Refer Artifacts for Form
EDC (Name of candidate/Employee
team. ID/Name of Company needs to be
2. Experi highlighted by the SPOC)
ence
documen
ts to be
collected
Proof to be collected for (DOJ, LWD / LDO OR BOTH)
and
checked
for the
number
of years
indicated
as
experien
ce in the Form / 4) Email from Last employer confirming DOJ & / OR LWD or email initiated
Application
Prosp
e c t i vbye our HR/Recruitment Team to candidate's last employer for confirmation
E m p l o y e e Detail’s, of his/her DOJ & / OR LWD.
3. In case O R
C o p y of resignation email mentioning the last working day which is sent
of any
cutting
related to
work
the experience
Application on to the relevant people/ department of the concerned company from
form official email id with acknowledgment from Company's official ID as
/ " A c c e p te d/R Yes Yes
Prospe
ctive Yes Yes Yes Yes
e c e iv e d ".
Employee Detail’s, OR
resulting Copy of resignation email along
in salary with the last working day from
change, personal
file would email ID to official Email ID
with acknowledgment from
be sent back to the Company's official ID as "Accepted/Received" along with Any official
recruiter to issue
an
 document issued by the company on a Letter Head with Authorized
addendu Compensation.
m with 4. Any other correction on the

revised
S mentioning DOJ (if DOJ not mentioned
i in the email/artifacts).
g
n 5 ) A n y o ff ic ia l d o c u m e n t i s s u e d b y
th e co m p an A yuto h
n oa riz
L ee ttd eSr H
i g ena ad towr i ie
th s m e n t io n in g
D O J & L W D / L D O / D a t e o f r eli e v ing / Contract a
t
o

r
i
e

s
Application Form / End Date is mentioned (Please mention the document name)
EmPrpolsopyecetiD vetailOsR
Rehire
(For Concentrix Rehire Check Yes Yes Yes Yes
Yes
Candidate) Form
can be Note: Refer to FAQ for Document Types. Yes
corrected
and
signed by
the
candidate
&
recruiter
with
recruiters
EMP ID.
Please note: The objective of the exercise is to have proof of employment of the candidate with that
organization clearly indicating the DOJ and LWD/LDO.
1. Therefore any one or combination of the above listed documents must be collected as a proof/artifact

for DOJ or Last Day in organizations.

2. Respective HR onboarding Spoc must check the authenticity/correctness of the document by

validating them against originals

3. Second level of validation will be done by EDC team to ensure complete set of documents have been
Check not to
submitted and there is no mismatch of information between various documents submitted. be done by
3 Photographs – 02 Passport Size Photographs of Self (most Yes EDC
recent)
Yes
4 No Hire University / Company Check
conducted NA
CNXALL/ONB/ART/ONBP/JCL/4.0
 ONBOARDING CHECKLIST
Name of Candidate: DESETTI SIVASAI KUMAR
Serial No. Documents required Onboarding EDC
SPOC SPOC/Top X
SPOC
5
PHOTO Any Photo Id proof issued by Govt Body (Pls mention the document Y  NA
IDENTIFICATI name) e
ON PROOF s
DOCUMENTS
(Self
Attested)
1) Photo copy of PAN Card / Internet Copy with PAN number
(In case PAN card is not available, then OPTION 2 needs to be filled) No
6 Yes
Note: Pan card copy "Will be Accepted" as a DOB proof but Pan Card Internet
PAN Copy "Will
Details Not Be Accepted" as DOB proof
Any ONE Yes NA
of the 2 2) PAN Application acknowledgement receipt along with PAN Undertaking
options

7 1) Is passport available? (Note: in case the employee is not able to submit, he Yes No CL 12 to CL 11:
Passport needs to be informed of the timeline by when passport has to be submitted as per EDC SPOC
(Mandatory passport process - HR Onboarding SPOC responsible). to check copy
requirement of the
for CL 10 passport, if
and above) "YES" is ticked
Any ONE of in point 1
No CL 10 and
the 3 2) CL 10 and above employees, Passport is a mandatory requirement: - Does Yes above: EDC
options the employee have a valid passport? SPOC to only
In case
check for a
passport is 3)  NA passport or
provided, - If "No" has been selected in the above point, Is the passport application
Y applied for
the same receipt submitted by the candidate? OR
es status, else
can be used - Is the passport application status available online?
employee ID
as DOB
should not be
proof.
created
 Yes  NA
8 Photocopy of Aadhaar Card / E-Aadhaar Copy with number
Mandatory Joining Documents
9 Joining Report  Yes  NA
10 Agreement Regarding Confidential Information, Intellectual Property, and Other  Yes  NA
Matters (NDA)
11 Composite Declaration Form - 11  Yes  NA
12 PF Form 2 (Revised) - 1 Copy (In case of any hiring is not done through One Touch  Yes  NA
it should have 2 copies of PF Form 2)
13 Gratuity form (Form 'F')  Yes  NA
14 Form I (Nomination & Declaration)  Yes  NA
Criminal Background Verification Form (Applicable for CL 12 to CL 11  Yes  NA
15 employee’s not submitting valid copy of Passport) Note: Candidate
should sign the form and photograph.
16 Name mentioned in Application Form / Prospective Employee Detail’s Form  Yes  NA
should match with the Aadhaar Card
Non - Mandatory Joining Documents (if applicable)
ESI (1copy) & one postcard size photographs (HEAD TO TOE), in case
require dependent spouse /children / parents to be covered, then the
17 postcard photograph should be along with them.  Yes  NA
Note: The photograph should cover the
“"Full Body "” preferably with white
background Only Passport Size
Photograph required (For
Mumbai,Thane,Pune & Vadodra )
 18 Physically challenged (PWD) and Salary equal to or less than Rs. 25000/-; If yes  Yes  NA
then ESI

form to be filled. If No, then please tick NA.

19 Foreign National Proof Document (Work permit \ Visa \ SSN)  Yes  NA
20 Joining Bonus (If Applicable)  Yes  NA Check not to
be done by
EDC
21 PROPRIETARY INFORMATION AND INVENTIONS AGREEMENT  Yes  NA
22 CONFLICT OF INTEREST DISCLOSURE FORM  Yes  NA
23 COEBC-Receipt of Acknowledgement  Yes  NA

Name of Onboarding SPOC: Nasir Pasha

Date (dd/mm/yy):

Employee ID of Onboarding SPOC: 216102 Signature:

Certify that
photocopies
have been
verified with
originals
(Onboarding
SPOC)
CNXALL/ONB/ART/ONBP/JCL/4.0
 TRANSPORT RULES

I, DESETTI SIVASAI KUMAR, agree and acknowledge that I have been provided transport facilities by Concentrix
Corporation (hereinafter, “Concentrix”) for commuting to and from the office. I hereby confirm that I have read and
understood the below rules relating to the transport facilities and undertake to follow these rules. In addition, I shall
follow all other directives issued by the Company from time to time with respect to the Company transport facilities.
All other applicable rules and regulations of the Company shall continue to apply to my use of the transport facilities.

I confirm that I shall adhere to all rules applicable to the transport facilities. A current copy of these rules has
been reproduced below.

“As an employee of Concentrix, you are expected to: -

 Be present at the designated place and time for boarding your cab.
 Board and De-Board the cab in a safe manner and only after the vehicle has come to a complete halt.
 In case of “First Female Boarding and Last Drop” (FFBLD) scenarios (i.e. if you are a female employee who
is being picked up first or being dropped last on a route, between 7 p.m. and 7 a.m. (West Region i.e. Pune
& Mumbai FFBLD window timing is 8:30 PM to 7 AM) DO NOT, under any circumstances, board without a
male employee / Security guard being present, demand that a Security Guard be present in the cab. It is a
serious violation of Concentrix Policy, it also jeopardizes employee safety. This rule is valid despite any
instructions you may receive from any party, including your reporting manager.
 Note down and carry with you the Centralized Emergency
Helpdesk Contact Numbers for all the Legacy CNX location:

Sahayata - 1800-123-7752 / 1800-419-0654 (2nd Option)

- Vizag: 9160758892
- Hyderabad: 9515101071
- Chennai: 9790998999
- Bangalore: Millennium Tower, PTP - 9743800076 / Manyata (MTP) - 9901442338 / PSN &
BCPV–9945680680 /Ecospace- 9743800075
- NCR/Chandigarh: 0124-4717444
- Noida: 0120-3817819
- Mumbai: 022-40605777
- Pune: 8308995441
- Kolkata: 9830370700 / 033-66344217

Kindly feed the Toll-Free No. 1800 200 1988 if you are in Pune, NCR/ Chandigarh / Bangalore.

Numbers for all the New CNX location:

Transport Helpline -Toll free no: 1800-208-1000 (Except Hyderabad)

Emergency numbers:

- Hyderabad- 9515101071(emergency & Helpline)

- Bangalore-9739080080
- Gurgaon - 9999256000
- Thane -9833809888
- Pune -9923000770

Release 2.0

Document Owner India SO & Transport Leader

 Always keep the doors of a moving cab locked.
 Always wear seatbelts, especially if you are traveling on the front seat.
 Always treat your driver with respect. Do not be rude to the driver or provide instructions– he is an employee of someone
else.
 Confirm the authenticity of the cab before boarding it.
 If you are a Cab Leader (i.e. if you are the first to be picked up or the last to be dropped, ensure that all cab users
fill up and sign the Cab Reporting / Departure Slip. As a Cab Leader do take responsibility for safe conduct of co
passengers, especially female colleagues. At the time of drop Cab Leader needs to make sure that female
employee should not be dropped last or picked up first in absence of security Guard.
 Assist the driver in following traffic rules.
 If the driver engages in rash driving while driving, stop the cab immediately and contact the Centralized Emergency
Helpdesk.
 If the driver is feeling sleeping during driving, stop the cab immediately and contact the Centralized Emergency Helpdesk.
 Wear & Display your id card while boarding the cabs.
 Call up Centralized Emergency Helpdesk and your Manager if you notice or are subjected to any
suspicious or inappropriate behavior during the journey.

This would include but is not limited to the following:

✓ Personal / intrusive questions

✓ Questions / comments of sexual nature
✓ Threatening behavior of any sort
✓ Staring/ inappropriate visual or facial behavior
✓ Inappropriate physical contact
✓ Requests for money or financial assistance
✓ Any other behavior that you consider unsafe or that merits the attention of the Transport Department

 If the driver threatens you, report the matter to the Emergency Helpline.
 Keep the FM/ Music at a low volume.
 Cabs will be utilized for official duties only.
 If the driver asks for money, report the matter to the Emergency Helpline.
 Report any service lapse or traffic violation to the Emergency Helpline.
 Don’t board the cab if the driver does not have a visibly seen and valid ID Card, or if you believe that it is another person.
 Don’t delay departure of the cab – it leads to penalty to the driver and to his vendor.
 Don’t get into an argument with the driver / vendor's supervisor. Instead, report the matter to the Transport Executive.
 Don’t take any personal favors from drivers or become familiar with them.
 Don’t display unethical behavior
 Do not indulge in falsification of log sheets
 Don’t consume alcohol or any other contraband substances while traveling in the cab. It is a violation of transport
policy as well as the law.
 Don’t smoke inside the cab –you will be fined. Don’t carry hazardous materials / Unethical substances in the cab.
It is a violation of the law.
 Don’t fall asleep if you are on the front seat.
 Women employees are NOT permitted to sit on the front seat – it is a violation of Company policy.
 Don’t try to drive the cab under any circumstances. It is a violation of the Company Policy.
 Don’t allow non- Concentrix employees to travel in the cab.
 If you carry / wear expensive items while traveling in the cab, you do so at your own risk.

Release 2.0

Document Owner India SO & Transport Leader

 Don’t divulge personal information while traveling in the cab – do NOT reveal your cell number to anyone you do not know.
 Don’t request the driver for a change of route – it is strictly prohibited.
 Don’t ask for unscheduled stops – it has safety implications and is violation of Company policy.
 Do not deviate the cab from the scheduled route – it will result in serious action against defaulters.
 Do not request drivers to pick up or drop from locations other than specified in the routes
 Do not behave or appear in such a manner that encourages an unwarranted approach from the driver or others.
 Do not discuss / disclose any confidential business information.”
 Employee will login / logout on driver device on their own and where ever applicable will sign the CRS.
 Do not engage yourself with your co passengers for any kind of social/ personal/controversial topics which
makes negative impression and tends to create any unwanted issue. Employees are responsible for the
safety of their personal belongings.

I confirm that I have read the above and agree to comply with them. I understand and acknowledge that any breach of
these may attract disciplinary action as the Company deems fit.

Name:

Signature:

Date:

Release 2.0

Document Owner India SO & Transport Leader

 SELF-TRANSPORT UNDERTAKING

DECLARATION FOR NOT AVAILING COMPANY TRANSPORT

I am aware that I may avail of free company-provided transport and security facilities for travel between my residence and workplace,
if I am required to work from office between 7.00 PM and 7.00 AM for any reasons whatsoever.

However, for personal reasons, and on my own volition, I hereby declare that I will not avail company-provided transport but will make
my own arrangements for transport between 7:00 PM and 7:00 AM. (In Maharashtra i.e. Pune & Mumbai timing between 8:30 PM to 7
AM)

I am aware of, and fully understand the risks involved with not using Company-provided transport during the above hours. I have
considered these risks and have taken the decision to make my own transport arrangements, keeping in mind my convenience and
personal preferences.

I understand and acknowledge that I will be responsible for my safety and security once I leave the Company premises and while
commuting to and from office. I am voluntarily making my own transport arrangements and I will be responsible for the consequences
thereof. I understand and acknowledge that Concentrix (which includes Concentrix Daksh Services India Private Limited or
Concentrix Services India Private Limited or Concentrix Technologies India Private Limited or Convergys India Services Private
Limited as applicable) will have no liability whatsoever arising out of this and I waive any claims that I may have against Concentrix in
this respect.

I am aware that I may avail of the transport and security facility provided by Concentrix at any point of time, by suitably notifying the
transport operations team of Concentrix.

Thanking you

Your’s sincerely,

Employee Name:

EMP ID /Applicant ID: 00410040066

Designation: Representative, Operations

Employees’s Signature

Date:

I have read, understood, and acknowledge and agree with the above declaration in its entirety.
Dear Manager,

I am employed with Concentrix Daksh Services India Private Limited.

I will abide by the company policies, processes and guidelines.

However, if I will be part of any internal/domestic inquiry during my tenure in the organization, the investigation team
may inspect my system, mobile details or anything that supports during the investigation to decipher the truth in the
interest of company.

I hereby declare that I shall share the required data and details on my own accord and without any pressure from the
company.

I have read, understood and acknowledge and agree with the above declaration in its

entirety. Thanking You,

Employee Name: Date :

Signature:
1. I DESETTI SIVASAI KUMAR, working with Concentrix (which includes Concentrix Daksh Services India Private Limited or
Concentrix Services India Private Limited or Concentrix Technologies India Private Limited or Convergys India Services
Private Limited as applicable)), declare and confirm as follows: I understand and agree that, as part of the ongoing
attendance process, Concentrix is authorized to collect my biometric information (fingerprints), for the purposes of verifying
and validating my identity and map the same to hours productivity analysis and reporting. I understand and agree that
Biometric Swipe in and Swipe Out data will be used as my attendance input for Payroll computation and payment.

2. I hereby provide my explicit consent for Concentrix to collect, retain, handle and otherwise process such biometric
informati on for attendance, verification and similar authentication purposes, during the course of my employment with
Concentrix.

3. I understand and agree that Concentrix may authorize third parties to collect, store, handle, process, or otherwise use such
biometric information for the purposes contemplated under this consent form (including for any purposes related to, incidental
to or necessary to accomplish such purposes) and has provided me with the necessary information relating to the same. I
explicitly consent to Concentrix disclosing or transferring my biometric information to such third parties, whether located in
India or outside India. I understand that Concentrix shall require such third parties to follow levels of data protection similar to
that followed by Concentrix, or as required by applicable law. The name and address of any such third parties that handle my
biometric information shall be provided to me on request.

4. I understand that I may seek to review the biometric information provided by me and retained by Concentrix.

5. I understand that if I have any queries or grievances related to the biometric information provided by me, I may contact my HR
partner.

6. I further understand that this authorization and consent is provided solely for the purpose as specified above. I
understand that Concentrix shall treat my biometric information disclosed to it as confidential. Concentrix shall use
appropriate security standards to keep my biometric information confidential.

Date:

Signature of Employee:
 Undertaking

I DESETTI SIVASAI KUMAR, (S/O) (D/O) DESETTI SAMBA SIVA RAO having his/her
permanent residing address at 37-12-64/5/A/SF-201, ANJINADRI ENCLAVE, NGOS
COLONY, NG
,VISAKHAPATNAM,Andhra Pradesh,530007, working with CONCENTRIX DAKSH SERVICES INDIA PVT
LTD
[Link]-9-13-45-2/9/4(3), WARD NO-16
7TH FLOOR, SRK DESTINY, VIP ROAD, VIZAG-530003 as Representative, Operations
hereby execute this undertaking in relation to the awareness
session having complete understanding about the Sexual Harassment of Women at Workplace
(Prevention, Prohibition and Redressal) Act (“Act “), 2013.

I further undertake that I have gone through the complete session and have understood the
information provided to me.

Signed by

Name -

Designatio

n - Date -

# NAME COMPANY EMPLOYEE SIGNATURE

1.

2.

3.
4.
5.

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 # NAME COMPANY EMPLOYEE SIGNATURE

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 # NAME COMPANY EMPLOYEE SIGNATURE

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# NAME COMPANY EMPLOYEE

SIGNATURE

1.

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# NAME COMPANY EMPLOYEE

SIGNATURE

9.

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# NAME COMPANY EMPLOYEE

SIGNATURE

29.

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# NAME COMPANY EMPLOYEE

SIGNATURE

47.

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# NAME COMPANY EMPLOYEE

SIGNATURE

68.

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 # NAME COMPANY EMPLOYEE

SIGNATURE

91.

92.

93.

94.

95.

96.

97.

98.

99.

Name of Address of the family member Date of Relationship with

S. No. Address
Name Birth member
(1) (2) (3) (4) (5)

4
[Link] of person making
nomination (in block letters)
 [Link]'s/Husband's Name
[Link] of Birth
[Link]
[Link] Status
[Link] Address

[Link] Address

I hereby nominate the person(s)/cancel the nomination made by me

previously and nominate the person(s) mentioned below to receive any
amount due to me from the employer, in the event to my death.
x
1. Advertisement Number & Sr. No. :

2. Application for the post of :

3. Name of the applicant :

4. Date and place of birth :

5. Age :

Nationality :
6.
7. Marital Status :

8. Whether belongs to SC/ST/OBC :

community (if so, give details and
attach copy of certificate)

9. Religion :
10. Disability :
(attach photocopy of certificate)

11. Permanent address :

12. Address for correspondence :

with telephone/mobile
number and e-mail address

13. Qualifications (beginning with SSC or equivalent. Attach photocopies of all certificates and mark lists
of all semesters/years) :

Examination University/ Subjects Year of %of marks & Class/

Degree/Diploma Institute Passing Grade/
distinction
obtained
14. Other qualification (if any) :

15. Details of projects done( if any) :

16. Details of publications (if any) :

17. Are you employed in a Govt./Semi-

Govt./:
Public Sector Undertaking/Autonomous
body? (If yes, you are required to
forward
your application through proper
channel)

18. Are you under any contractual

obligation :
to serve the Govt./Semi-Govt./Public Sector
Undertaking/Autonomous body? If yes, give details.

19. Experience/Details of present and previous employment (attach photocopies of experience certificates) :

Name of Employer Designation of Period of Service Salary

the post held From To

20. Names and addresses of two referees : 1)

2)

21. Have you at any time been called: for interview in the
Centre? If so, give details:

I' hereby declare that the statements made in this application are true, complete and correct to the best of my knowledge
and belief.

Place:

Date: (Signature of the candidate)

Please fill the application form

“Employer” Position applying for

PERSONAL DATA
Name (last, first, middle)

Street Address and/or Mailing Address City State Zip

Home Telephone Number Business Telephone Number Cellular Telephone Number

Date you can start work Salary Desired Do you have a High School Diploma or GED?
Yes No
POSITION INFORMATION Check all that you are willing to work
Hours: Full Swing
Time Days Status: Regula
Part Gravey
Time Eveni a r
n gs rd Tempor
Weekends a ry
Are you authorized to work in the U.S. on an Yes No
unrestricted basis?

Have you ever been convicted of a felony? (Convictions will not necessarily Yes No
disqualify an applicant for employment.) If yes, explain:
Have you been told the essential functions of the job or have you been viewed a copy of the job
description listing the essential functions of the job? Yes No
Can you perform these essential functions of the job with or without reasonable accommodation? Yes No
QUALIFICATIONS Please list any education or training you feel relates to the position applied for that would help
you perform the work, such as schools, colleges, degrees, vocational or technical programs, and military training.

School Name Degree Address/City/State

School

School

Other

SPECIAL SKILLS List any special skills or experience that you feel would help you in the position that you are applying for
(leadership, organizations/teams, etc.

REFERENCES Please list three professional references not related to you, with full name, address,
phone number, and relationship. If you don’t have three professional references, then list personal,
unrelated references.

Name Address/City/State Phone Relationship

 WORK HISTORY Start with your present or most recent employment and work back. Use separate sheet if necessary.
(INCLUDE PAID A
UNPAID POSITIONS)
Job Title #1 Start Date (mo/day/yr) End Date (mo/day/yr)

Company Name Supervisor’s Name Phone Number

City State Zip

Duties:

Reason for Leaving Starting Salary Ending Salary

May we contact your present employer? Yes No N/A

Job Title #2 Start Date (mo/day/yr) End Date (mo/day/yr)

Company Name Supervisor’s Name Phone Number

City State Zip

Duties:

Reason for Leaving Starting Salary Ending Salary

Job Title #3 Start Date (mo/day/yr) End Date (mo/day/yr)

Company Name Supervisor’s Name Phone Number

City State Zip

Duties:

Reason for Leaving Starting Salary Ending Salary

Job Title #4 Start Date (mo/day/yr) End Date (mo/day/yr)

Company Name Supervisor’s Name Phone Number

City State Zip

Duties:

Reason for Leaving Starting Salary Ending Salary

Applicant Signature Date

 Affix recent
Post Applied For: -------------------------------------------- Photograph

1. Personal Details

a) Name :

b) Father’s Name/Husband’s Name :

c) Date of Birth :

d) Age as on today :

e) Sex :

f) Marital Status :

g) Category (SC/ST/OBC/GEN) :

h) Nationality :

Af

2. Address for Correspondence / Permanent Address

Address :

Telephone Number

Mobile Number

E-Mail

3. Academic Qualifications

Examination Passed :

Name of Institution / Board :

Year of Passing :

% of Marks :
Driver *
LMV Licence No : Date of expired:
HMV Licence No. : Date of expired:

Stenographer*

Typing
Language
Lower (Yes / No) Higher (Yes / No)
English

Tamil

* Enclose relevant certificates with this application

4. Past Experience:

Organization :

Designation :

Pay Scale :

Period :

Job Description :

Total experience :
 :

Please put your signature

1. NAME OF CANDIDATE: across the photograph.

FIRST NAME:

MIDDLE NAME:

SURNAME:

2. FATHER’S NAME:

3. MOTHER’S NAME:

4) GENDER: MALE FEMALE

5) DATE OF BIRTH (DD/MM/YYYY)

6) AGE (as on 01-01-2017) Years Months Days

7) PERMANENT ADDRESS:

P.O
City

District.

State.

Pin code:
8) ADDRESS FOR CORRESPONDENCE:

P.O
City.

District.

State.

Pin Code

9) MOBILE NUMBER:

10) E- MAIL ID:

11) EDUCATIONAL QUALIFICATIONS.

QUALIFICATION/NAME SUBJECTS/ YEAR OF GRADE /

OF COURSE UNIVERSITY/BOARD SPECIALIZATION PASSING PERCENTAGE

12) PROFESSIONAL EXPERIENCE:

Employment details (Please add extra sheets if required)

DURATION
SL DESIGNATION ORGANIZATION. Total Job Responsibilities
From To
NO (in months)

Total Experience: (................... yrs................... M...........days)

13) TRAINING AND OTHER COURSES ATTENDED.

DURATION
SL NAME OF TRAINING /
OTHER NO COURSES ATTENDED NAME OF INSTITUTE From To Total

14) LANGUAGE KNOWN: (PLEASE TICK √ )

SL
LANGUAGE WRITING READING SPEAKING
NO

Declaration:

I hereby declare that all the statements made by me in the application form and information sheet are
true and complete to the best of my knowledge and belief and nothing has been concealed or
suppressed. I also understand that in case, any of my statements is found untrue during any stage of
recruitment and thereafter, I shall be disqualified for the post applied for and I shall be liable for any
penal action.

Date: Signature of the Candidate

Place:
 Signature / Left Thumb Impression

1 Full Name (Full expanded name to be mentioned as appearing in proof of identity/date of birth/address documents: initials are not permitted)

Please select title,  as applicable Shri Smt. Kumari

M/s Last Name / Surname
First Name
Middle
Name
2 Abbreviations of the above name, as you would like it, to be printed on the PAN card

3 Have you ever been known by any other name?

Yes No (please tick as applicable)

If yes, please give that other name

4 Gender (for Individual applicants only) Male Female Transgender (please tick as applicable)
5 Date of Birth/Incorporation/Agreement/Partnership or Trust Deed/ Formation of Body of individuals or Association of Persons
Day Month Year

6 Details of Parents (applicable only for individual applicants)

Whether mother is a single parent and you wish to apply for PAN by furnishing the name of your mother only?
Yes No (please tick as applicable)
If yes, please fill in mother’s name in the appropriate space provide below.
Father’s Name (Manda tory except where mother is a single parent and PAN is applied by furnishing the name of mother only)
Last Name /
Surname First
Name
Middle Name
Mother’s Name (optional except where mother is a single parent and PAN is applied by furnishing the name of mother only)
Last Name /
Surname First
Name
Middle Name
Select the name of either father or mother which you may like to be printed on PAN card
(Select one only) Father’s name Mother’s name (Please tick as applicable)
(In case no option is provided then PAN card will be issued with father’s name except where mother is a single parent and you
wish to apply for PAN by furnishing name of the mother only)’.
7 Address
Residence Address
Flat / Room / Door / Block No.
Name of Premises / Building /
Village Road / Street /
Lane/Post Office
Area / Locality / Taluka/ Sub-
Division Town / City / District
State / Union Territory Pincode / Zip code Country Name
 Office Address
Name of office
Flat / Room / Door / Block No.
Name of Premises / Building /
Village Road / Street /
Lane/Post Office
Area / Locality / Taluka/ Sub- Division
Town / City / District
State / Union Territory Pincode / Zip code Country Name

8 Address for Communication Residence Office (Please tick as applicable)

9 Telephone Number & Email ID details
Country code Area/STD Code Telephone / Mobile number

Email ID

10 Status of applicant

Please select status,  as applicable Government

Individual Hindu undivided family Company Partnership Firm Association of Persons

Trusts Body of Individuals Local Authority Artificial Juridical Persons Limited Liability
Partnership
11 Registration Number (for company, firms, LLPs etc.)

12 In case of a person, who is required to quote Aadhaar number or the Enrolment ID of Aadhaar application form as per section 139 AA
Please mention your AADHAAR number (if allotted)
If AADHAAR number is not allotted, please mention the enrolment ID of Aadhaar

application form Name as per AADHAAR letter or card or as per the Enrolment ID of

Aadhaar application form

13 Source of Income Please select,  as applicable

Salary
Capital Gains
Income from Business / Profession Business/Profession code [For Code: Refer
Income from Other
instructions] Income from House property sources No income
14 Representative Assessee (RA)
Full name, address of the Representative Assessee, who is assessible under the Income Tax Act in respect of the person, whose
particulars have been given in the column 1-13.
Full Name (Full expanded name : initials are not permitted)

Please select title,  as applicable Shri Smt. Kumari

M/s Last Name / Surname
First Name
Middle
Name
Address
Flat / Room / Door / Block No.
Name of Premises / Building /
Village Road / Street / Lane/Post
Office Area / Locality / Taluka/
Sub- Division
Town / City / District
State / Union Territory Pincode

15 Documents submitted as Proof of Identity (POI), Proof of Address (POA) and Proof of Date of Birth (POB)
I/We have enclosed as proof of identity,
as proof of address and as proof of date of birth.
 [Please refer to the instructions (as specified in Rule 114 of I.T. Rules, 1962) for list of mandatory certified documents to be submitted
as applicable] [Annexure A, Annexure B & Annexure C are to be used wherever applicable]
16 I/We , the applicant, in the capacity
of
do hereby declare that what is stated above is true to the best of my/our information
and belief.

Place
:
D D M M Y Y Y Y

Date
:
Item
Item Details Guidelines for filling the form
No.
1 Please select appropriate title.
Do not use abbreviations in the First and the Last name/Surname. written as :

Last
Name/Surname

First Name

Middle Name

F
FATHER NAME

Last
Name/Surname

First Name

Middle Name

MOTHER NAME

Last
Name/Surname

First Name

Middle Name

MANAGER NAME

Last
Name/Surname

First Name

Middle Name

TEAM LEADER NAME

HR NAME

Last
Name/Surname

First Name

Middle Name

PROJECT HEAD NAME

Last
Name/Surname

First Name
 Middle Name

ASSISTANT MANAGER
Last
Name/Surname

First Name

Middle Name

2 FLOOR SECRETARY NAME

Last
Name/Surname

First Name

Middle Name

15 Proof of It is mandatory to attach proof of identity, proof of address and proof of date of birth with
Identity, Proof PAN application. Documents should be in the name of applicant. List of documents which will
of Address and serve as proof of identity, address and date of birth for each status of applicant is as
Proof of Date given below:
of Birth
documents

(Signature of Candidate)
Code Business/ Profession Code Business/ Profession
01 Medical Profession and Business 11
02 Engineering 12
03 Architecture 13

04 Chartered Accountant/ 14
Accountancy
05 Interior Decoration 15

06 Technical Consultancy 16

Plying Taxis, Lorries, Trucks, Buses or

07 Company Secretary 17
other Commercial Vehicles
08 Legal Practitioner and Solicitors 18 Ownership of Horses or Jockeys
09 Government Contractors 19 Cinema Halls and Other Theatres
10 Insurance Agency 20 Others
 1 Name (in Block Letters) :

2 Father’s/Husband’s Name :

3 Date of birth :

4 Sex :

5 Marital Status :

6 Account No. (PF/EPS Number) :

7 Address (Residential) :

Name and Address of Nominees Date of Birth Total amount If the nominee is minor, name and
the relationsh of share relationship and address of the
nominee/nominees ip with o guardian who may receive the
the f amount during the minority of
member accumulatio nominee
ns
is Provident
Fund to be
paid to

each
nominee (%)
(1) (2) (3) (4) (5)

1 * Certified that I have no family as defined in para 2(g) of the Employees’ Provident Funds Scheme, 1952, and should
I acquire a family hereafter, the above nomination should be deemed as cancelled.
2 * Certified that my father/mother is/are dependent upon me.
3. * Strike out whichever is not applicable.
X----------------------------------------------------------------
Signature or thumb impression of the