Background Verification Form
Reference No(Mandatory for BASS)
Name of Applicant
(Last, First, Middle)
Date of Joining Bajaj Allianz*
Employee Code
Maiden Name :
Have you ever been known by another YES NO
name?
If Yes, please write the other name:
Place of Birth: Date of Birth (dd/mm/yy):
Gender : Nationality:
Father’s Name: Passport No. SSN No.
(Mandatory for US address)
Home Phone Office Phone Mobile
RESIDENTIAL ADDRESS
Permanent Address
City : State :
Pin Code : **Nearest Landmark :
Name of the 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 & Address of Name & Address of Type of Dates Attended Roll Number/
School/College/Institute University its affiliated Degree/Diplom Registration
a obtained. Number/Exam
State “F” for From To Seat number
fulltime and
“P” for part-
time within
brackets
EMPLOYMENT RECORD
If you are still employed in your current 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 ID From (mm/yy) To (mm/yy)
Full Name
Address Phone Number
City State Country Postal Code
Permanent (onrolls) or temporary (contractual)
Agency Details (if temporary/contractual)
Job Title Reason of Leaving
Designation Final Salary (Annual CTC)
Supervisor Name & Title HR Manager Name
Supervisor ‘s Phone Number HR Manager Phone Number
Verified by:
Sign: _______________________
Name in Block Capitals:______________________
Date: ________________________
Information Release Form
To Whom It May Concern:
Please print
I_______________________________________________________________________
Last name First name Middle name
I hereby authorize my current/prospective employer and/or or their authorized representatives and contractors 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
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.
of my qualification/degree (copy of my certificates attached)
information in respect to my character from the records maintained by local authorities
Signature: Date: dd / mm / yyyy
