Background Verification Form
Employee Code: Employee Location: Vijayapura
PERSONAL DETAILS
Name of Applicant
First – Sharan
Middle –
Surname – S V
Maiden Name:
Have you ever been known by YES NO
another name?
If Yes, please write the other name:
Place of Birth: Date of Birth (dd/mm/yy): 14/05/1996
Sex: Male Nationality: India
Father’s Name – Passport No. SSN No.
VASUDEVA S D (Mandatory for US address)
Home Phone: Office Phone: Mobile - 7338085472
RESIDENTIAL ADDRESS (Please mention all the addresses you have resided since clearing
your higher secondary examination) Copy paste the address grid as per requirement and
addresses resided.
Permanent Address Sugatur (V)
Jangamakote(P)
Shidlagatta (T)
Chikkaballapur(D)
City: Chikkaballapur State: Karanataka
Pin Code: 562102 Nearest Landmark:
Name of the contact person at the address: Vasudeva S D
Relationship of contact person: Father
Landline No. Mobile No.: 7338085472
Nature of Location: Rented/Owned/Others Preferred time of the day for conducting the
verification, if any:
Owned
Residing Since (Mandatory): Residing Till (Mandatory):
Current Address 3 37 Ward No.21, near kuvempu circle, vijayapura
City: Devanahalli State: Karanataka
Pin: 562135 Nearest Landmark: Temple
Contact Person at the address: Manohar
Relationship of contact person: Brother
Landline No. Mobile No.: 7338085472
Nature of Location: Rented/Owned/Others Preferred time of the day for conducting the
verification, if any:
Residing Since (Mandatory): Residing Till (Mandatory):
Address 2
City: State:
Pin: Nearest Landmark:
Contact Person at the address:
Relationship of contact person:
Landline No. Mobile No.
Nature of Location: Rented/Owned/Others Preferred time of the day for conducting the
verification, if any:
Residing Since (Mandatory): Residing Till (Mandatory):
Education Record
EDUCATION RECORD (Start with the latest/ highest qualification; please attach photocopies
of the documents) All fields are mandatory
Name & Name & Address of Type of Dates Attended Roll
Address of University its affiliated Degree/Dipl Number/Regis
School/College oma tration
/Institute obtained. From To Number/Exam
State “F” Seat number
for fulltime
and “P” for
part-time
within
brackets
Sit Mvit VTU MBA 2017 2019 1mz17MBA46
PFGC BANGALORE B>COM 2014 2017
PROFESSIONAL EDUCATION RECORD
PROFESSIONAL EDUCATION RECORD
(Start with the latest/ highest qualification; please attach photocopies of the documents ) All
fields are mandatory
Name & Address of Name & Address Type of Dates Attended Roll
School/College/Insti of University its Degree/Dipl Number/Regis
tute affiliated oma tration
obtained. From To Number/Exam
(Mandatory) (Mandatory)
State “F” Seat number
for fulltime
and “P” for
part-time
within
brackets
EMPLOYMENT RECORD
If you are still employed in this organization, please fill in the date before which you would not like the
verification to be initiated in the “To” column. If you are not sure or would like to intimate this date
later, please write 'Still Employed'
Employer 1 Employee From (mm/yy) To (mm/yy)
ID
Full Name
Address Phone Number
City State Country Postal Code
Job Title Reason of Leaving
Designation: Final Salary (Annual CTC):
Supervisor Name & Title HR Manager Name
Supervisor ‘s Phone Number & HR Manager Phone Number & Official email id
Official email id
EMPLOYMENT RECORD
Employer 2 Employee From To (mm/yy)
ID (mm/yy)
Full Name
Address Phone Number
City State Country Postal Code
Job Title Reason of Leaving
Designation: Final Salary (Annual CTC):
Supervisor Name & Title HR Manager Name
Supervisor ‘s Phone Number & HR Manager Phone Number & Official email id
Official email id
EMPLOYMENT RECORD
Employer 3 Employee From To (mm/yy)
ID (mm/yy)
Full Name
Address Phone Number
City State Country Postal Code
Job Title Reason of Leaving: -
Designation: Final Salary (Annual CTC):
Supervisor Name & Title HR Manager Name
Supervisor ‘s Phone Number & HR Manager Phone Number & Official email id
Official email id
REFERENCE DETAILS
(1) Full name of the Sowmya DV
Reference
(Professional)
Telephone # and email ID 9845930129
Organization SLK
Relationship with the Friend
candidate
REFERENCE DETAILS
(2) Full name of the
Reference
(Professional)
Telephone # and Email ID
Organization
Relationship with the
candidate
Information Release Form
To Whom It May Concern:
Please print
I__ ______________ ___________________ __________
Last name First name Middle name
I hereby authorize KPMG or their representatives to verify information presented on my employment
application/resume and to procure an investigative report or consumer report for that purpose.
I hereby grant authority for the bearer of this letter to access or be provided with full details
n of my previous employment record held by any company or business for whom I previously
worked. This information should include the dates of employment; the nature of the position
held, [details of my salary upon departure] and an appraisal of my performance, capabilities
and character. In addition, please provide any other pertinent information requested by the
individual presenting this authority. I hereby release from liability all persons or entities
requesting or supplying such information.
n of my qualification/degree (copy of my certificates attached)
n information in respect to my character from the records maintained by local authorities
Signature: Date: dd / mm / yy
Checklist
Background verification form filled in with correct information and legible handwriting along
with manually signed LOA.
1. For Education Verification:
Kindly ensure a clear and uncut copy of the degree certificate and final year mark sheet
bearing seat number/Roll number is provided for avoiding insufficiencies at a later stage.
2. For Employment Verification:
Clear and uncut photocopy of the relieving and experience certificates, employee id,
relevant documents like pay slips, offer letter, etc. are provided for avoiding insufficiencies
at a later stage.
3. For Criminal Verification and Database:
Photo id proof would be required for avoiding insufficiencies at a later stage.
4. For Address verification:
Complete address mentioning: Survey number, Plot number, Flat number, Lane Number,
Door number, nearest landmark, Society/Area name, Pin code.
Correct period of stay, working contact details along with supporting documents for the
address proof will be required for avoiding insufficiencies at a later stage.
5. For Reference Check: Complete contact details like email id and working contact details
would be required.
