CANDIDATE APPLICATION FORM
01. Please legibly complete the form in your handwriting or on Word Document
02. Please mark the correct option
03. (*) is Mandatory for all candidates
04. (**) is Mandatory for all the Experienced Candidates only
05. Please mention the date wherever required
*Name in Full
DEEPAK C
(in BLOCK
Letters) First Name Middle Name Last Name
*Father’s CHOODESH B
/Spouse Name …………………………………………………………………………………..
*PAN Card *Aadhar Card No
GXSPD5660L 882553838217
number …………… ……………………… ………………………
**PF No ………………………
PYKRP00355530000123992 **UAN No ………………………...
102027282493
Passport No Valid Till
Visa Details Visa Type: Country and Valid Till ( DD/MM/YYYY) :
Date : DD/MM/YYYY Work Location:
Date of Joining 05/05/2025 bagmane solarium city
*Permanent Address *Address for Communication
#108/6/4 near srinivas kalyana mantapa, B D C road bilekahalli, bilekahalli banglore-76
banglore south banglore karnataka-560076
Address *Mobile No.8618909621
…………………………
Landline:…..………………………… deepaknc077@gmail.com
*Email: ………………………..……
*Birth Detail *Date of Birth: 12/04/2002 *Age: 23 *Place of Birth BANGLORE
*Nationality: Indian *Gender: Male ✔ Female Transgender
*Marital *Yes *No: ✔
Status
*Bank Name: HDFC BANK *IFSC Code: HDFC0000075
*Bank Details
*A/C No: 50100671043133 *Branch Address:bengaluru-560017
Old airport road,murgeshpalya,
*Contact Details * Mobile:8618909621 *Emergency Contact (Name and Phone) :
8618909621
Primary Email : eepaknc077@gmail.com
*Personal Email Address
Secondary Email :
Eligible for Pension -(An individual who joined the Employees' Provident Fund (EPF) scheme, after
September 1, 2014, is not eligible for Employees' Pension Scheme (EPS) account if his/her basic
*Details of Eligibility for salary exceeds Rs 15,000)
Pension Yes :
No: ✔
www.carelonglobal.com *Candidate’s Signature & Date
* Family Details
Aadhar Occupation
Date of Birth
Relationship Name Card
(DD/MMYYYY)
Number
Father
Mother
Spouse
Brother/Sister
*Education Details
School/ Area of Total Percentage
Year Passing
University Specialization Or Rating
10th Standard
12th Standard
Graduation
Post Graduation
Other Certification
Gaps in Education
(if any)
**Work Experience Details
**Organization **From **To **Duration **Designation **Reason for
In months Separation
Gaps in Employment
(if any)
Yes No
International Worker
Work Permit Details ( Work Permit number/OCI number : Valid Till Date : DD/MM/YYYY
Mandatory only for
International Workers)
*Candidate’s Signature & Date
www.carelonglobal.com
**List two professional references
S No. **Name & Address **Occupation **Email **Mobile
Do you know anyone working at Carelon at Present?
(If Yes, please list them below)
S No. Name & Address Function Designation Relationship
I understand and acknowledge that submission of information and documents in this application form does not constitute
any form of relationship, employment or otherwise, with Carelon.
I hereby declare and represent that all the contents of my resume, testimonials, references, previous employment details
and other information furnished in this application form are true and accurate. If any of the above particulars are found
at any time to be incorrect or misleading in any way, Carelon shall have the right to terminate any possible employment
for misconduct, without the requirement of providing me any notice or compensation in lieu thereof.
CANDIDATE APPLICATION FORM
Have you applied for a role at Carelon previously: Yes No
If yes, please provide details:
Are you employed as
Director in any company: Yes No
Partner in any company: Yes No
If yes, please provide details
How did you come to know about the current job opening? Provide details
Consultant Employee Referral Job Posting
*Candidate’s Signature & Date
www.carelonglobal.com
*To whomsoever it may concern
I hereby authorize Carelon to verify the information and/or documents mentioned in my application form, either from an
outside background screening agency and/or directly, which includes my current/previous employment history,
educational/professional credentials and my criminal/address background check at any time. I understand and acknowledge
that any possible employment with Carelon is conditional upon the satisfactory background checks conducted on me at any
time.
I understand, agree and consent that Carelon and/or the outside background screening agency may contact and obtain
appropriate information from different sources as per the details mentioned in my application form submitted to Carelon ,
which includes employment history from my current/previous employer, educational/professional credentials to be checked
from school/college/university/autonomous institute and my criminal/address background check from civil/credit violations
records in compliance with applicable law.
I understand and agree that the outside background screening agency respectively reserve the rights to obtain appropriate
information / documents from any individual, corporation or any confidential information deemed necessary to check my
credentials and furnish the same to Carelon hereunder and I expressly consent to the same.
I unconditionally release Carelon and all concerned parties hereunder from all liabilities that might arise as a result of my
background verification check and also do not hold responsible, any individual, corporation or private and public entity as a
consequence of this check.
I also authorize release of this information to Carelon / the outside background screening agency in original, fax or
photocopy form as deemed necessary and authenticate the validity of the same.
*Candidate’s Signature & Date
www.carelonglobal.com
